Every finding on record at Baptist Health Nursing and Rehabilitation Center

Based on observation, record review, and interview during survey, the facility failed to ensure that the residents' environment remained as free of accident hazards as possible for five (Resident #s 17, 80, 151, 161, and 162) of 18 residents reviewed for accidents. Specifically, (1) on 08/17/2025, Resident #17 was provided with an alternate meal (egg salad sandwich) upon request, which was not according to the resident's prescribed diet order of puree texture (a cohesive, smooth texture free of lumps and coarse particles that does not require chewing) diet, thin consistency fluids. As a result, Resident #17 sustained a choking occurrence, their skin turned blue, and they required the Heimlich maneuver. (2) Medications were observed unattended at the residents' bedside for Resident #s 80, 151, 161, and 162, observations were made daily starting on the first day of survey 06/08/2026 through and including the last day of survey on 06/15/2026. This resulted in actual harm to Resident # 17 that was not Immediate Jeopardy. Findings include: (1) Resident #17: Resident #17 was admitted with diagnoses that included dysphagia (difficulty swallowing) and congestive heart failure (a long-term condition where the heart's main pumping chamber weakens and cannot squeeze properly). The Minimum Data Set (a resident assessment tool) dated 08/08/2025, documented the resident had moderate cognitive impairment, was on a mechanically altered diet and required supervision or touching assistance for eating. The At Risk for Potential Alteration in Nutrition Comprehensive Care Plan initiated on 09/28/2022, documented the interventions including puree textures dated 06/17/2025. The physician's orders active on 08/17/2025, documented a diet order dated 06/17/2025, puree texture diet, thin consistency related to dysphagia. The Nursing Progress Note dated 08/17/2025 documented Licensed Practical Nurse #11 was alerted to resident choking in the dining room at 5:00-5:15 PM. Upon approaching the resident, the resident was seen flailing their arms and their spouse was yelling. Resident #17 was unable to speak, pointing to their throat. The resident appeared to be cyanotic (blueish discoloration around lips, skin, nails indicating a lack of oxygen) and the nurse began to perform Heimlich maneuver. After 45 seconds, a large piece of egg salad sandwich came up. The facility Incident Report dated 08/17/2025 documented Resident #17 was eating in the dining room and was noted to begin choking. Heimlich maneuver was performed, and food was successfully removed. The Employee Corrective Action dated 08/22/2025 documented a verbal warning to Certified Nurse Aide # 5, description included: on 08/17/2025, Certified Nurse Aide #5 gave Resident #17 an egg salad sandwich, violating their care plan. Employee comments included: when the resident asked for a sandwich, they went to the nurse and asked if the resident could have it, the nurse said it was okay. Signed and dated 09/02/2025. The Five-Day Investigation Report, dated 08/22/2025, documented the incident was a result of a care plan violation. During an interview on 06/15/2026 8:15 AM with Certified Nurse Aide #5, they stated Resident #17 was in the dining room and did not want the meal offered. After asking a nurse, Certified Nurse Aide #5 stated they gave an egg salad sandwich to Resident # 17 and went into the hall to pass trays. The nurse informed them the resident had taken one bite and started to choke and received the Heimlich maneuver. During an interview on 6/15/2026 at 11:02 AM with Medical Director #1, they stated that a resident who received a sandwich who was on a puree diet would be at risk of choking. They further stated that there were reasons why a resident would be on a puree diet, as the risk for aspiration is high. Medical Director #1 stated if the resident on a puree diet received an egg salad sandwich and it caused them to choke, and the Heimlich Maneuver was performed, then there was harm to the resident. (2) The facility policy titled Self-Administration of Medications initiated 05/04/2019 last revised 12/2025, documented residents have the right to self-administer medications if the Interdisciplinary Team determined that it was clinically appropriate and safe for the resident to do so. The staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate. This assessment may have the team determine that the resident cannot safely administer medications, and all medications would be administered by the nurse from the stored medications in the medication cart. It further stated that staff should identify and give the Charge Nurse any medications found at the bedside that are not authorized for self-administration. Resident #80: Resident #80 was admitted to the facility with diagnoses of tinea cruris (fungal skin infection), chronic gout (long term inflammatory arthritis), and type two diabetes mellitus (body cannot use insulin correctly and sugar builds up in the blood). The Minimum Data Set, dated [DATE], documented that the resident could be understood, could understand others, and was cognitively intact. Two prescription bottles of Nystatin powder labeled with dispensing information were observed on the shelf attached to the wall next to the resident's bed throughout the survey from 06/08/2026 through 06/15/2026. Review of Self Medication Assessment for resident #80 dated 05/12/2026 documented the resident was not approved to self-administer medication or keep medications at bedside. Review of prescriber orders documented an order for Nystatin External Powder 100000 UNIT/Gram (Nystatin (Topical). Apply to skin topically every day and evening shift for irritation. Resident # 162: Resident #162 was admitted to the facility with diagnoses of mild cognitive impairment of uncertain or unknown etiology (a stage of slight decline in memory and thinking skills), atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in the heart's natural arteries without causing chest pain), and chronic systolic congestive heart failure (a long-term condition where the heart's main pumping chamber weakens and cannot squeeze properly) The Minimum Data Set, dated [DATE], documented the resident could make themselves understood, understood others, and had moderate cognitive impairment. Review of Resident #162's Comprehensive Care Plan noted there was no documented evidence it was clinically appropriate or safe for the resident to self-administer medications. Nursing Self-Administration of Medication assessment dated [DATE] documented Resident #162 required assistance for storing medication in a secure location, administering oral medications, stating the proper dosage, dispensing the proper amount, and identifying situations requiring the administration of as needed medications. It further documented the resident was not approved for self-administration of medications and they may not keep medications at the bedside. During an observation on 06/08/2026 at 3:18 PM, Resident #162 was sitting in their wheelchair in their room, which was shared with another resident. A half-full bottle of diphenhydramine HCl (hydrochloride) nighttime sleep aide (an over-the-counter antihistamine that temporarily relieves occasional sleeplessness by blocking histamine in the central nervous system, promoting drowsiness) was on the resident's overbed table. During an interview on 06/08/2026 at 3:18 PM, Resident #162 stated their spouse brought in the medication for them and they take it when they cannot sleep. During an interview on 06/10/2026 at 10:16 AM, Licensed Practical Nurse #6 stated there should be no prescribed treatment medications or over-the-counter medications at a resident's bedside. During an interview on 06/11/2026 at 12:30 PM, Licensed Practical Nurse #9 stated they did not have any residents on the unit that self-administer medications. If the resident could self-administer medications, it would be documented in the physician order for that medication and the comprehensive care plan. Residents should not have medications at their bedside if they are not approved to self-administer medications due to safety reasons. During an interview on 06/10/2026 at 11:27 AM, Registered Nurse #1 stated there were no residents approved for medications at bedside or self-administration of medication on the unit. Nystatin powder or over the counter medications should not be present in any room. During an interview on 06/12/2026 at 2:34 PM, Director of Nursing #1 stated residents needed to be assessed to determine if they were safe to self-administer medications. If a resident was determined not to be safe to self-administer medications, they should not have medications in their room. This applied to over-the counter-medications as well. During an interview on 06/15/2026 at 9:13 AM, Administrator #1 stated there was an assessment tool to evaluate a resident's safety for self-administration of medication. If the resident was not safe to self-administer medications, they should not have medications in their room. This applied to over-the counter medication as well. 10 New York Codes Rules and Regulations 415.12 (h)(1)

Based on observations, record reviews, and interviews during the survey, the facility failed to establish and maintain an infection prevention and control program in accordance with professional standards of practice. Specifically, a) hand hygiene between rooms was not performed; b) sanitary transport of dirty linens and garbage was not performed; c) dressing supplies that were to be used were placed on the floor; d) urinary catheter drainage bags were observed to be resting on the floor. Findings include: The policy and procedure titled Isolation Precautions System, dated 04/2025, stated a two-tiered system of isolation was used, including standard precautions and transmission-based precautions. Enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of targeted multidrug resistant organisms. Enhanced barrier precautions were to be used when a resident had an external medical device such as a urinary catheter, feeding tubes or drains, and also for wounds that typically required dressing changes (excluding small skin breaks/tears/abrasions that could be covered with a simple adhesive bandage). Contact precautions were to be used to reduce the transmission of epidemiologically important microorganisms which might be spread by direct or indirect contact. This included instructions to wear gloves and a gown before entering the room under contact precautions if direct care was anticipated. If indirect contact, like delivering a food tray, was anticipated, gloves and gown were not needed, but hands must be washed prior to leaving room. During a dining observation on 06/08/2026 at 12:21 PM, staff did not offer to sanitize/clean residents' hands prior to dining. During an observation on 06/08/2026 at 12:45 PM, Certified Nurse Aide #6 entered a room with a posted enhanced barrier precautions sign to deliver a food tray, then walked into another room to deliver a food tray, then walked into another resident's room and did not perform hand hygiene between the three rooms. The posted enhanced barrier precautions sign stated everyone was to clean hands before entering and when leaving the room. During observations on 06/08/2026 and 06/09/2026, indwelling urinary catheter drainage bags were on the floor. During an observation on 06/10/2026 at 03:09 PM, Certified Nurse Aide #7 was in a room with a dirty linen bag that was open and had an incontinence garment and gloves falling out of the bag. During a wound care observation on 06/10/2026 at 01:44 PM, Licensed Practical Nurse #7 placed dressing change supplies on a resident's overbed table without cleansing the surface or placing a drape. During a wound care observation on 06/11/2026 at 12:30 PM, Licensed Practical Nurse #6 placed the dressing change supplies on the floor. During an interview on 06/08/2026 at 01:17 PM, Certified Nurse Aide #6 stated they should have washed their hands after setting up the resident's meal tray before exiting the room. During an interview on 06/10/2026 at 01:44 PM, Licensed Practical Nurse #7 stated they didn't know when the overbed table had been cleaned last and should have placed a drape on the table before setting out the dressing change supplies. During an interview on 06/10/2026 at 06/10/2026 at 03:09 PM, Certified Nurse Aide #7 stated they had brought the linen bag in from another room and the dirty incontinence garment was from another room. During an interview on 06/11/2026 at 10:35 AM, Infection Preventionist #1 stated indwelling urinary catheter drainage bags should not touch the floor. They stated dirty linen and garbage bags should not be transported from one resident's room to another; it should be disposed of in the dirty linen room before entering another resident's room. They stated that dressing change supplies should be laid out on a clean surface which did not include the floor or an unwiped bedside table, and a drape should be used. During an interview on 06/15/2026 at 09:13 AM, Administrator #1 stated they would expect staff to offer assistance or opportunity for residents to wash their hands prior to eating. They would expect hand hygiene between resident rooms. 10 New York Codes, Rules, and Regulations 415.19 (b)(4)

Based on observation, record review, and interviews during the survey, the facility failed to prepare and serve food in accordance with professional standards for food service safety in the main kitchen and 6 of 6 nourishment stations. Specifically, food was not stored properly; the automatic dishwashing machine was not operating within the manufacturer specifications; the concentration of the chemical sanitizing rinse was less than that required by the manufacturer; and food preparation area equipment, floors, walls, and ceilings required cleaning & repair. The findings include:During observations on 06/08/2026 at 9:34 AM:Pureed breakfast muffins were stored below raw beef patties in walk-in refrigerator; Director of Dining Services #1 stated that the pureed muffins were fully cooked but would be reheated before being served; [NAME] #1 did not know the temperature to reheat food (pureed muffins). The automatic dishwashing machine final rinse temperature was 120 degrees Fahrenheit at zero pounds per square inch of water pressure; dishwashing machine data plate stated that the final rinse was to be 180 degrees Fahrenheit at 15 to 25 pounds per square inch of water pressure.The concentration of quaternary ammonium compound in the 3-bay sink sanitizing rinse was zero parts per million; the label directions state solution is to be between 200 and 400 parts per million.Kitchen coving tiles and the floor by service entrance was cracked and/or broken.The bottom cover was missing from stove exposing electronic & control mechanisms.The following equipment required cleaning: can opener, knife rack, toaster, stove, convection oven, steam kettle, shelving, preparation sink, handwashing sinks, refrigerators, chest freezer, walk-in refrigerator door, wall fan, K-rated fire extinguisher.The following areas required cleaning: floor under equipment & next to walls, kitchen walls & doors, ceiling & vent ducts, food service office. During observations on 06/08/2026 at 10:42 AM, 6 of 6 nourishment station refrigerators, sinks, floors, and/or cabinetry required cleaning. During an interview on 06/08/2026 at 11:26 AM, Director of Dining Services #1 stated that they would do the following:Re-educate the cooks on reheating temperatures.Contact the vendors to adjust the dishwashing machine final temperature and adjust the concentration of sanitizer in the 3-bay sinkFollow up with the maintenance department to install the missing piece on the stove, repair the floor & coving tiles, clean the ceiling, and repair the cabinets in the nourishment areas.The kitchen equipment and floors & walls and the items in the unit nourishment stations would be cleaned. New York Codes, Rules, and Regulations Title 10 S415.14(h)Chapter 1 State Sanitary Code Subpart 14-1

Based on record reviews, observations, and interviews conducted during the survey, the facility failed to provide services by sufficient numbers of staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Specifically, one Certified Nurse Aid was alone on unit H1 during the day shift on 06/09/2026, and one Certified Nurse Aid was left alone on unit H2 during the day shift on 06/11/2026. Findings include: Observations: During an observation on 06/09/2026 of Unit H2, Resident #87 placed call bell at 11:04 AM, Licensed Practical Nurse #5 answered the call bell at 11:07 AM. They then looked for an available Certified Nurse Aide to assist the Resident. There were two Certified Nurse Aides and one Licensed Practical Nurse in the break room on unit, located across hall from the resident's room. During an observation on 06/11/2026 at 11:45 AM on unit H1, there were multiple residents in the common area, there were no staff observed on the unit until 11:52 AM. Interviews: During an interview on 06/09/20206 at 11:10 AM, Licensed Practical Nurse #5 stated that the staff in the break area were on break. There were four Certified Nurse Aides and two Licensed Practical Nurses on the unit for that shift. One Certified Nurse Aide and one Licensed Practical Nurse were off the floor on break, two Certified Nurse Aides and one Licensed Practical Nurse were in the staff breakroom. Leaving one Certified Nurse Aide on the floor at that time. Subsequently, on 06/12/2026 at 9:20 AM, they stated one staff member should not be left alone on the floor while all other staff were on break. They were unaware on 06/09/20206 at 11 AM that was the case. They stated H2 generally has one Licensed Practical Nurse for each shift, and the Licensed Practical Nurse was typically late passing medications because of this. During an interview on 06/11/2026 at 11:52 AM, Certified Nurse Assistant #9 stated they were alone on the unit. There was one other Certified Nurse Aide and one Licensed Practical nurse on the unit for the shift, and they both were on break of the floor. They were still getting residents up for lunch at that time and there was no one to supervise the common area. If a Resident had a fall or anything else occurred, they would be unaware while they were providing care in a room. They stated they have difficulty getting everyone up before lunch in general with two Certified Nurse Assistants on the day shift, there had been an increase in residents that required two people to assist. During an interview on 06/11/2026 at 12:00 PM, Director of Nursing #1 stated one Certified Nurse alone on the unit was not expectable, especially during the day shift. One person should not be on the floor alone. Subsequently on 06/12/2026 at 2:35 PM, they stated medications being administered late due to one Licensed Practical Nurse on the floor for the shift was not acceptable and would indicate the unit was not adequately staffed. During an Interview on 06/15/2026 at 11:45 AM, Registered Nurse #1 stated it was not acceptable for one Certified Nurse Aide to be on the unit with all other staff on break. They were not aware that one staff member was left on the floor during the day shift on H1. 10 New York Codes Rules and Regulations 483.35(a)(1)

Based on observations, record reviews, and interviews during the survey, the facility failed to ensure drug records were in order. Specifically, narcotic shift to shift count sheets were not completed every shift for two of five narcotic shift to shift count books reviewed. The policy and procedure titled Controlled Substances, dated 12/2021, stated that each narcotic dose is removed from the package to be noted on the control record as follows: date, time, dose, balance of remaining, and name/title. The policy and procedure titled Controlled Medication Storage, effective 08/2025, stated, At the beginning and end of each shift, all controlled substances would be accounted for by having two nurses (one from the present and one from the oncoming shift) count and sign the appropriate accountability records. Review of the narcotic shift to shift count book on unit H-1 on 06/10/2026 at 10:16 AM documented multiple missing signatures. There were no signatures for any shift from 06/08/2026 to 06/10/2026 at the time of the observation and review. Review of the narcotic shift to shift count book on unit H-3 on 06/10/2026 at 11:20 AM documented multiple missing signatures between 06/02/2026 and 06/10/2026. During an observed medication pass on 06/10/2026 at 10:16 AM, Licensed Practical Nurse #6 did not immediately sign the narcotic record that two narcotic medications were administered. During an interview on 06/10/2026 at 10:46 AM, Licensed Practical Nurse #8 stated the shift-to-shift book should be signed each shift with the appropriate count. They stated the book should have double signatures on each line for each shift. They stated they should have signed the narcotic sheets when they gave the narcotic , but stated that, as there was one book at the nursing station for both carts, it was harder to sign for individual needs. During an interview on 06/10/2026 at 11:07 AM, Licensed Practical Nurse #6 stated the narcotic books should be signed every shift but the book had run out of papers so there were no signatures. They stated that individual narcotic medications should be documented when they were given. During an interview on 06/10/2026 at 11:27 AM, Registered Nurse #1 stated the book should be signed with every shift and at the time of medication administration. During an interview on 06/10/2026 at 12:49 PM, Director of Nursing #1 stated the expectation was the count should be done and signed every time the narcotic keys were exchanged. They stated the books should be signed with every medication administration at that time. During an interview on 06/12/2026 at 09:20 AM, Licensed Practical Nurse #5 stated the narcotic counts should be done and signed for every shift and medications should be signed for individually when they were administered throughout the shift. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on record reviews and interviews conducted during the survey, the facility failed to ensure residents were given the right to be informed in advance, of the risks and benefits of the proposed treatment, and the ability to choose the alternative or option they preferred by the physician or other practitioner for three of five residents reviewed. Specifically, Resident #s 12, 19, and 87, were prescribed psychotropic medications without consent obtained. Findings include: The facility policy titled Psychotropic Medications-Unnecessary Use revised 05/2026 documented, there was to be documentation of discussion with the resident and /or responsible party regarding the risk versus benefit of the use of the medication. Resident #12 : Resident #12 was admitted to the facility with diagnoses of bipolar disorder, in partial remission, (chronic mental health condition characterized by extreme mood fluctuations), anxiety disorder (common mental health condition that involves excessive fear, worry, or nervousness that interferes with daily life), and an infection with an inflammatory reaction due to an indwelling urethral catheter (a tube inserted through the urethra into the bladder to drain urine, prolonged use can lead to infection and inflammatory reactions). The Minimum Data Set, dated [DATE], documented that the resident could usually be understood, could understand others, and was mildly cognitively impaired. Review of provider orders documented: Doxepin HCl Oral Capsule 100 Milligrams (Doxepin HCl) Give 1 capsule by mouth at bedtime for Depression Quetiapine Fumarate Oral Tablet 25 Milligrams (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime Paroxetine HCl Oral Tablet 30 Milligrams (Paroxetine HCl) Give 1 tablet by mouth at bedtime for Depression Divalproex Sodium Oral Tablet Delayed Release 250 Milligrams (Divalproex Sodium) Give 1 tablet by mouth three times a day Divalproex Sodium Oral Tablet Delayed Release 500 Milligrams (Divalproex Sodium) Give 1 tablet by mouth three times a day Lithium Carbonate Oral Capsule 300 Milligrams (Lithium Carbonate) Give 1 capsule by mouth two times a day Psychotropic medication consents requested from the facility for Resident #12 on 06/10/2026 and 06/11/2026, received by facility 06/12/2026 at 8:29 AM. Consents were signed and dated 06/11/2026. Resident #19 Review of provider orders documented: Mirtazapine Oral Tablet 7.5 Milligrams Give 1 tablet by mouth at bedtime for depression Prazosin HCl Oral Capsule 5 Milligrams Give 2 capsules by mouth at bedtime for Post Traumatic Stress Disorder Seroquel Oral Tablet 25 Milligram Give 25 milligram by mouth two times a day for schizoaffective disorder Sertraline HCl Oral Tablet 50 Milligram Give 1 tablet by mouth one time a day for Depression There was no documented evidence of Psychotropic medication consent. Resident #87 Resident #87 was admitted to the facility with diagnoses of major depressive disorder, recurrent (a mood disorder that causes a persistent feeling of sadness and loss of interest), chronic respiratory failure with hypoxia (when the respiratory system fails to maintain adequate gas exchange, resulting in low oxygen levels), and dependence on supplemental oxygen (medical condition in which a person requires oxygen therapy for an extended period to maintain adequate oxygen levels in the blood). The Minimum Data Set, dated [DATE], documented that the resident could be understood, could understand others, and was mildly cognitively impaired. Review of provider orders documented orders for: Escitalopram Oxalate Oral Tablet 10 Milligrams (Escitalopram Oxalate) Give 10 milligrams by mouth one time a day for depression give with 20 milligram tab for Total Dose=30mg Escitalopram Oxalate Oral Tablet 20 Milligrams (Escitalopram Oxalate) Give 20 milligrams by mouth one time a day for depression give with 10 milligram tab for Total Dose=30mg Trazadone HCl Oral Tablet 50 Milligram (Trazodone HCl) Give 50 milligram by mouth at bedtime for depression Klonopin Oral Tablet 0.5 Milligram (Clonazepam) Give 1 tablet by mouth four times a day for anxiety for 14 Days Psychotropic medication consents requested from the facility for Resident #87 on 06/10/2026 and 06/11/2026, received by facility 06/12/2026 at 8:29 AM. Consents were signed and dated 06/11/2026. Interviews: During an interview 06/12/2026 at 9:20 AM, Licensed Practical Nurse #5 stated they had worked in the facility 32 years and had never been made aware until yesterday consents for psychotropic medications needed to be obtained. During an interview 06/15/2026 at 11:02 AM, Medical Director #1 stated medication including psychotropic medication required consents are to be obtained prior to starting and/or if a change has been made. The family needs to be notified of any new medication or medication changes. During an interview on 06/12/2026 at 2:35 PM, Director of Nursing #1 stated psychotropic medications were to be completed with the start of a new medication, the facility was not completing psychotropic medication consents prior to 06/11/2026. Moving forward gradual dose reduction attempts will trigger notification and consents. 10 New York Codes Rules and Regulations 415.3(e)(1)(i)

Based on observation and interviews conducted during the survey, the facility failed to provide effective housekeeping and maintenance services on six of 6 resident units and the service areas. Specifically, floors, walls, ceilings, and dining tables were not clean and/or maintained; plumbing was in disrepair. The findings include: During observations on 06/11/2026 at 10:40 AM through 12:17 PM and again on 06/12/2026 at 9:15 through 12:00 PM:The main kitchen had an open drain and standing water under pre-rinse sink; the pre-rinse sink was plumbed to a sump pump system in the Boiler Room.The S unit Boiler Room had leaking pipes with standing water on the floor, was littered with trash, and had a sump pump system with an open wastewater collection tub.The dietary employee locker room floors, walls, doors, and lockers were heavily soiled; the walls below the sinks in the men's room had unfinished & unsealed repair work.The following areas were soiled with dirt, grime, food particles, or a black build-up: service area door thresholds, undersides of all dining room tables, ceiling vents.Ceiling tiles were stained in the H-1 unit nurse station.Throughout the S-2 unit, ceiling tiles were stained; corridor walls had small holes, scratch marks, and patched repairs were not painted, handrails were scratched, and heat registers in resident rooms were rusty.Throughout the N unit, walls & doors were scraped (door to room [ROOM NUMBER] was very badly scraped) and patched repairs were not painted; the floors room #s #2269 & 3369 were covered with dust balls. During an interview on 06/12/2026 at 12:09 PM, Director of Facilities #1 stated that they would:Clean the tables, floors, and vents.Repair & paint the walls.Replace the stained ceiling tiles.Have a licensed plumber repair the leaks in the boiler room to address the standing water and in the main kitchen, address the standing water, seal the open drain, and repair the prerinse sink drain to have the sump pump and open wastewater collection tub removed from the boiler room. New York Codes, Rules, and Regulations Title 10 S415.5 (h)(4); 415.29 (g), (i)(2)

Based on observations, record reviews, and interviews during the survey, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls. Specifically, treatment carts were left unlocked, a medication (pain-relieving cream) was left unattended on top of a cart, an inhaler was undated and unlabeled, and temperature logs were not completed on two of three medication refrigerators. Findings include: The policy and procedure titled Storage of Medications, dated 09/2024, stated drugs and biologicals used in the facility were to be stored in locked compartments under proper temperature, light, and humidity controls. Nurses were responsible for maintaining medication storage and preparation areas in a clean, safe, and solitary manner. During an observation on 06/10/2026 on a medication cart on H-1, a pain-relieving cream was on top of a medication cart unattended, insulin pens were not in bags, and five tablets were loose (out of package) inside the medication cart. During an observation on 06/10/2026 at 11:00 AM, the medication room on H1 had a medication refrigerator with incomplete temperature logs. During an observation on 06/10/2026 at 11:26 AM, a treatment cart on H-3 was observed to be unlocked and unattended. During an observation on 06/10/2026 at 10:46 AM, a medication cart on H-2 an inhaler was undated and unlabeled. During an observation on 06/11/2026 at 12:35 PM, a treatment cart on H-3 was observed to be unlocked and unattended. During an observation on 06/12/2026 at 9:10 AM, a medication cart on H-1 was left unlocked and unattended. Licensed Practical Nurse #6 was observed to be in a resident's room and could not see the medication cart. During an observation on 06/12/2026 at 09:16 AM, the medication room on H3 had a medication refrigerator with incomplete temperature logs. During an interview on 06/10/2026 at 10:16 AM, Licensed Practical Nurse #6 stated the temperature in the medication refrigerators were checked by the overnight shift. During an interview on 06/12/2026 at 09:20 AM, Licensed Practical Nurse #5 stated medication and treatment carts should always be locked when not in use and should not be left unlocked in the hallway. During an interview on 06/12/2026 at 02:39 PM, Director of Nursing #1 stated that medication and treatment carts should be locked, and temperature log sheets should be filled out as directed. During an interview on 06/15/2026 at 09:54 AM, Registered Nurse #1 stated all medication, and treatment carts should be locked. They stated the overnight shift should be checking and documenting the temperature of the refrigerators in the medication rooms. 10 New York Codes, Rules, and Regulations 415.18 (e) (1-4)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature. Specifically, (a.) five out of five residents during the resident council meeting on 06/09/2026 stated that the food was cold; (b.) Resident #80 stated that cold food was room temperature and hot food was cold; (c.) Resident #99 stated that sometimes the food was cold; and (d.) for Resident #110, food was not served at an appetizing temperature during a lunch meal on 06/11/2026 and stated that food was cold.Findings include: Facility policy titled Mealtime Management, General Principles Of revised 08/2025, documented the facility will provide nutritious, well-balanced meals to all residents/patients three times a day in a pleasant atmosphere. Under key points, it is documented to accommodate preferences as much as possible. During a surveyor-led resident council meeting on 06/09/2026 at 1:30 PM, five out of five residents stated and agreed that by the time food was served to them, the food was cold. Resident #80 Resident #80 was admitted to the facility with the diagnoses of dysphagia (difficulty swallowing), type two diabetes mellitus (a chronic condition that happens when a person has persistently high blood sugar levels), and unspecified diastolic (congestive) heart failure (a chronic condition where the heart is unable to pump blood effectively). The Minimum Data Set (an assessment tool) dated 06/16/2026, documented the resident understood others, was able to be understood, and was cognitively intact. During an interview on 06/08/2026 at 11:43 AM, Resident #80 stated that cold food was served at room temperature and hot food was served cold. Resident #99 Resident #99 was admitted to the facility with the diagnoses of Parkinson's Disease without dyskinesia (movement disorder of the nervous system that gets worse over time, without involuntary movements), pulmonary hypertension (a condition characterized by abnormally high blood pressure in the arteries of the lungs, which increases the workload on the right side of the heart), and unspecified diastolic (congestive) heart failure (a chronic condition where the heart is unable to pump blood effectively). The Minimum Data Set dated 04/08/2026, documented the resident understood others, was able to be understood, and was cognitively intact. During an interview on 06/08/2026 at 12:12 PM, Resident #99 stated that sometimes the food was served cold. Resident #110 Resident #110 was admitted to the facility with diagnoses of iron deficiency anemia (a condition in which the body lacks sufficient iron to produce healthy red blood cells, leading to reduced oxygen delivery to tissues), gastro-esophageal reflux disease without esophagitis (chronic digestive disorder in which stomach acid or contents flow back into the esophagus), and hypertension (high blood pressure). The Minimum Data Set dated 05/13/2026, documented the resident understood others, was able to be understood, and was cognitively intact. During an observation on 06/11/2026 at 12:17 PM, Resident #110's lunch meal contained the following items with temperatures measured as follows: Barbeque chicken thighs were 118.8 degrees Fahrenheit, rice pilaf was 114.3 degrees Fahrenheit, sauteed zucchini was 105.8 degrees Fahrenheit, orange juice was 68.4 degrees Fahrenheit, whole milk was 56.1 degrees Fahrenheit, and frosted banana cupcake 67.5 degrees Fahrenheit. After tasting the food and drink, the temperature of the entree was lukewarm, orange juice was barely chilled, and the milk was slightly cooler than the orange juice. During an interview on 06/08/2026 at 12:16 PM, Resident #110 stated that the food was served cold, and they did not receive hot food or drinks while at the facility. During an interview on 06/12/2026 at 11:21 AM, Director of Dining Services #1 stated that there were complaints about food temperatures from the residents. There were more complaints about hot foods not being hot. They were working towards getting new equipment to prevent foods from getting to an undesirable temperature. During an interview on 06/15/2026 at 9:13 AM, Administrator #1 stated that there were complaints from the residents about wanting food to be hotter when it was served to them. The complaints were typically that food was not hot enough. On the units with complaints, they encouraged residents to eat in the dining room since residents in the dining room tended to be served their meal trays immediately. They would like to have the food trucks replaced to help keep the meal trays at a more desirable temperature. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

During observations on 06/12/2026 at 11:35 AM, the facility grounds were overgrown with vegetation as follows:Weeds were growing in the gap between the asphalt and the building foundation.Weeds, grape vines, and tree saplings were growing in the landscape gardening found at the facility entrances and in the resident garden sanctuary courtyard.A large tree sapling was growing over the pad-mounted electrical transformer. During an interview on 06/12/2026 at 12:09 PM, Director of Facilities #1 stated that they would address the landscaping overgrowth. New York Codes, Rules, and Regulations Title 10 S415.5(h)(4)Based on observation and interviews conducted during the survey, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the exterior of the facility building and grounds were not maintained. The findings include:

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life. Specifically, (a) during a dining observation on 06/08/2026, plastic utensils were provided to residents during the lunch meal. (b) Resident #65's urinary catheter drainage bag was observed to be not covered by a dignity bag. (c) Resident #201's urinary catheter drainage bag was observed to be not covered by a dignity bag. Findings include: Facility Policy titled Maintaining Resident Dignity effective 09/2024, documented the mission of the facility was to provide loving care to all residents in a timely manner that bespeaks dignity, respect, compassion, sensitivity and concern. The facility promotes care for residents in a manner and environment that maintains or enhances each resident's dignity and respect in full recognition of their individuality. In their interactions with residents, staff carries out activities that assist the resident to maintain and enhance their self-esteem and self-worth. Respecting care needs included the best practice option of using dignity-enhancing tools, such as catheter bag covers, unless resident preference dictated otherwise. The dining experience included the best practice of promoting dignity in dining, such as avoidance of day-to-day use of plastic cutlery and paper/plastic dishware. During a dining observation during the lunch meal on 06/08/2026 at 12:21 PM, on the Homeward Bound unit, all residents were provided with plastic spoons on their lunch tray. The residents were only provided with a metal fork and knife. During a dining observation during the lunch meal on 06/08/2026 at 1:05 PM, on the H-1 unit, all residents' lunch trays had a single plastic bag that contained a plastic knife, spoon, and fork. The residents were not provided with any metal silverware. During an interview on 06/11/2026 at 12:04 PM, Resident #110 stated they sometimes received plastic utensils. They do not like to use plastic utensils because the plastic utensils were weak and it was hard to cut a big piece of meat with them. During an interview on 06/08/2026 at 1:17 PM, Certified Nurse Aide #6 stated they typically work on the Homeward Bound unit, and the residents usually have metal silverware. They stated that some of the residents had regular silverware and some residents were noted to have plastic spoons on their trays. During an interview on 06/11/2026 at 11:17 AM, Certified Nurse Aide #8 stated there have been a couple of times plastic utensils were served on resident meal trays. They stated that two weeks ago when the dishwasher was down, plastic utensils were served. During an interview on 06/11/2026 at 12:28 PM, Licensed Practical Nurse #9 stated that they serve plastic utensils to residents on contact precautions or if there are safety issues relating to the resident. They stated they do not serve plastic utensils because the plastic utensils could break off while being used which could be a choking hazard. During an interview on 06/12/2026 at 11:21 AM, Director of Dining Services #1 stated that the expectation was for residents to have appropriate silverware on their trays. They stated that silverware tends to disappear and it can be difficult to keep an appropriate amount of silverware in the facility. When they run out of silverware, plastic utensils were used. They stated that plastic utensils should not have been used during meal service this week and providing the residents with plastic utensils instead of metal silverware was a dignity concern. During an interview on 06/15/2026 at 9:13 AM, Administrator #1 stated they did not expect residents to be provided with plastic utensils during meals. They stated that plastic utensils would be served only if the dish machine was down or if there was an activity with food like ice cream. They stated that it was not a homelike environment when residents were provided with plastic utensils instead of metal silverware and it was not appropriate for dining. Resident #65 Resident #65 was admitted to the facility with the diagnoses of type two diabetes mellitus (a chronic condition where the body doesn't use insulin properly or can't make enough of it), chronic obstructive pulmonary disease (a progressive, incurable group of lung diseases that cause inflamed airways and airflow blockage), and obstructive and reflux uropathy (a blockage in the urinary tract that hinders normal urine flow causing urine to back up and swell the kidneys). The Minimum Data Set (an assessment tool) documented the resident was able to be understood, could understand others, and was cognitively intact. During observations on 06/08/2026, 06/09/2026, 06/10/2026, and 06/12/2026, the urinary catheter drainage bag of Resident #65 was visible from the door and not covered with a dignity bag. During an interview on 06/08/2026 at 11:50 AM, Resident #65 stated they were not aware the urinary catheter drainage bag should be covered and did not remember if they had been offered a cover. Resident #201 Resident #201 was admitted to the facility with diagnoses of dementia (loss of cognitive function), chronic kidney disease (when your kidneys stop filtering waste from your blood), and urinary tract infection (bacteria enters the urethra and infect the urinary tract). The Minimum Data Set, dated [DATE], documented that the resident could usually be understood, could usually understand others, and was severely cognitively impaired. During observations on 06/08/2026, 06/09/2026, 06/10/2026, 06/10/2026, 06/12/2026, and 06/15/2026, the urinary catheter drainage bag was visible from the door and not covered with a dignity bag. During an interview on 06/08/2026 at 11:33 AM, Certified Nurse Aide #13 stated the urinary catheter draining bag should be covered. During an interview on 06/08/2026 at 11:40 AM, Licensed Practical Nurse #1 stated the urinary catheter drainage bag should be covered. During an interview on 06/12/2026 at 2:35 PM, Director of Nursing #1 stated urinary catheter drainage bags should not be visible from the hallway and they should be covered. 10 New York Code of Rules and Regulations 415.5(a)

Based on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure a medication error rate of less than 5 percent. Specifically, medication error rate was observed to be 12.5 percent. Findings include: The policy and procedure titled Administration of Medications - General, revised 09/2024, stated medications were to be administered within one hour before or after the prescribed time. Resident #116 was admitted to the facility with diagnoses of dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life), anemia (the lack of healthy red blood cells or hemoglobin to carry adequate oxygen to tissues), and essential hypertension (high blood pressure). During an observation on 06/10/2026 at 11:30 AM, Licensed Practical Nurse #3 was observed administering medications scheduled for 9:00 AM at 11:30 AM for Resident #116. The medications were Amlodipine oral tablet 10 milligrams give 1 tablet by mouth one time a day for hypertension at 9:00 AM Sertraline hydrochloride 25 milligrams give 12.5 milligrams one time a day for depression at 9:00 AM Ferrous sulfate 325 (65 Iron) milligrams give 1 tablet by mouth two times a day at 9:00 AM and 6:00 PM Metoprolol tartrate give 12.5 mg by mouth two times a day for atrial fibrillation at 9:00 AM and 6:00 PM. During an interview on 06/10/2026 at 11:30 AM, Licensed Practical Nurse #3 stated the medications were late because they had arrived on shift at 8:30 AM. They stated they guessed they would notify the nurse manager who would notify the provider. They stated they didn't know when they would notify the nurse manager. During an interview on 06/12/2026 at 11:16 AM, Medical Doctor #1 stated they are notified through text message or phone call if a medication was not available, if it were a new medication that was missed. They stated they were not notified if the medication pass is administered late; they considered that a nursing issue. During an interview on 06/12/2026 at 11:40 AM, Nurse Practitioner #1 stated they had never been notified of a late medication pass or missed medications. During an interview on 06/12/2026 at 2:39 PM, Director of Nursing #1 stated the expectation was that the provider and family would be notified if a medication was late, refused or missed. During an interview on 06/15/2026 at 09:54 AM, Registered Nurse #1 stated they expected to be informed of any late medications, held medications, or unavailable medications. They stated they would then instruct the Licensed Practical Nurse to write a note about the late medications. They stated they would inform the provider if needed. They did not recall being informed of late medications over the last month. During an interview 06/15/2026 11:02 AM, Medical Director #1 stated they were not always notified of late medications, it was documented by the nurse. They expect for one of the Nurse Practitioners to be notified of late medications, and they would be notified if there was an adverse outcome or medications were missed. 10 New York Codes, Rules, and Regulations 415.12(m)(1)

Based on record review and interviews conducted during a survey, the facility failed to ensure that all alleged violations involving abuse were reported immediately, or no later than two hours after the allegation was made for one out of four incidents reviewed for abuse. Specifically, the facility did not report an incident with the allegation of sexual abuse between Resident #131 and Resident #151 within the two-hour reporting timeframe. Findings include: (1) Resident #17: Resident #17 was admitted with diagnoses that included dysphagia (difficulty swallowing) and congestive heart failure (a long-term condition where the heart's main pumping chamber weakens and cannot squeeze properly). The Minimum Data Set (a resident assessment tool) dated 08/08/2025, documented the resident had moderate cognitive impairment, was on a mechanically altered diet and required supervision or touching assistance for eating. The At Risk for Potential Alteration in Nutrition Comprehensive Care Plan initiated on 09/28/2022, documented the interventions including puree textures dated 06/17/2025. The physician's orders active on 08/17/2025, documented a diet order dated 06/17/2025, puree texture diet, thin consistency related to dysphagia. The Nursing Progress Note dated 08/17/2025 documented Licensed Practical Nurse #11 was alerted to resident choking in the dining room at 5:00-5:15 PM. Upon approaching the resident, the resident was seen flailing their arms and their spouse was yelling. Resident #17 was unable to speak, pointing to their throat. The resident appeared to be cyanotic (blueish discoloration around lips, skin, nails indicating a lack of oxygen) and the nurse began to perform Heimlich maneuver. After 45 seconds, a large piece of egg salad sandwich came up. The facility Incident Report dated 08/17/2025 documented Resident #17 was eating in the dining room and was noted to begin choking. Heimlich maneuver was performed, and food was successfully removed. The Employee Corrective Action dated 08/22/2025 documented a verbal warning to Certified Nurse Aide # 5, description included: on 08/17/2025, Certified Nurse Aide #5 gave Resident #17 an egg salad sandwich, violating their care plan. Employee comments included: when the resident asked for a sandwich, they went to the nurse and asked if the resident could have it, the nurse said it was okay. Signed and dated 09/02/2025. The Five-Day Investigation Report, dated 08/22/2025, documented the incident was a result of a care plan violation. During an interview on 06/15/2026 8:15 AM with Certified Nurse Aide #5, they stated Resident #17 was in the dining room and did not want the meal offered. After asking a nurse, Certified Nurse Aide #5 stated they gave an egg salad sandwich to Resident # 17 and went into the hall to pass trays. The nurse informed them the resident had taken one bite and started to choke and received the Heimlich maneuver. During an interview on 6/15/2026 at 11:02 AM with Medical Director #1, they stated that a resident who received a sandwich who was on a puree diet would be at risk of choking. They further stated that there were reasons why a resident would be on a puree diet, as the risk for aspiration is high. Medical Director #1 stated if the resident on a puree diet received an egg salad sandwich and it caused them to choke, and the Heimlich Maneuver was performed, then there was harm to the resident. (2) The facility policy titled Self-Administration of Medications initiated 05/04/2019 last revised 12/2025, documented residents have the right to self-administer medications if the Interdisciplinary Team determined that it was clinically appropriate and safe for the resident to do so. The staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate. This assessment may have the team determine that the resident cannot safely administer medications, and all medications would be administered by the nurse from the stored medications in the medication cart. It further stated that staff should identify and give the Charge Nurse any medications found at the bedside that are not authorized for self-administration. Resident #80: Resident #80 was admitted to the facility with diagnoses of tinea cruris (fungal skin infection), chronic gout (long term inflammatory arthritis), and type two diabetes mellitus (body cannot use insulin correctly and sugar builds up in the blood). The Minimum Data Set, dated [DATE], documented that the resident could be understood, could understand others, and was cognitively intact. Two prescription bottles of Nystatin powder labeled with dispensing information were observed on the shelf attached to the wall next to the resident's bed throughout the survey from 06/08/2026 through 06/15/2026. Review of Self Medication Assessment for resident #80 dated 05/12/2026 documented the resident was not approved to self-administer medication or keep medications at bedside. Review of prescriber orders documented an order for Nystatin External Powder 100000 UNIT/Gram (Nystatin (Topical). Apply to skin topically every day and evening shift for irritation. Resident # 162: Resident #162 was admitted to the facility with diagnoses of mild cognitive impairment of uncertain or unknown etiology (a stage of slight decline in memory and thinking skills), atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in the heart's natural arteries without causing chest pain), and chronic systolic congestive heart failure (a long-term condition where the heart's main pumping chamber weakens and cannot squeeze properly) The Minimum Data Set, dated [DATE], documented the resident could make themselves understood, understood others, and had moderate cognitive impairment. Review of Resident #162's Comprehensive Care Plan noted there was no documented evidence it was clinically appropriate or safe for the resident to self-administer medications. Nursing Self-Administration of Medication assessment dated [DATE] documented Resident #162 required assistance for storing medication in a secure location, administering oral medications, stating the proper dosage, dispensing the proper amount, and identifying situations requiring the administration of as needed medications. It further documented the resident was not approved for self-administration of medications and they may not keep medications at the bedside. During an observation on 06/08/2026 at 3:18 PM, Resident #162 was sitting in their wheelchair in their room, which was shared with another resident. A half-full bottle of diphenhydramine HCl (hydrochloride) nighttime sleep aide (an over-the-counter antihistamine that temporarily relieves occasional sleeplessness by blocking histamine in the central nervous system, promoting drowsiness) was on the resident's overbed table. During an interview on 06/08/2026 at 3:18 PM, Resident #162 stated their spouse brought in the medication for them and they take it when they cannot sleep. During an interview on 06/10/2026 at 10:16 AM, Licensed Practical Nurse #6 stated there should be no prescribed treatment medications or over-the-counter medications at a resident's bedside. During an interview on 06/11/2026 at 12:30 PM, Licensed Practical Nurse #9 stated they did not have any residents on the unit that self-administer medications. If the resident could self-administer medications, it would be documented in the physician order for that medication and the comprehensive care plan. Residents should not have medications at their bedside if they are not approved to self-administer medications due to safety reasons. During an interview on 06/10/2026 at 11:27 AM, Registered Nurse #1 stated there were no residents approved for medications at bedside or self-administration of medication on the unit. Nystatin powder or over the counter medications should not be present in any room. During an interview on 06/12/2026 at 2:34 PM, Director of Nursing #1 stated residents needed to be assessed to determine if they were safe to self-administer medications. If a resident was determined not to be safe to self-administer medications, they should not have medications in their room. This applied to over-the counter-medications as well. During an interview on 06/15/2026 at 9:13 AM, Administrator #1 stated there was an assessment tool to evaluate a resident's safety for self-administration of medication. If the resident was not safe to self-administer medications, they should not have medications in their room. This applied to over-the counter medication as well. 10 New York Codes Rules and Regulations 415.12 (h)(1)

Based on record reviews, observations, and interviews conducted during a survey, the facility failed to ensure residents were provided with treatment and care in accordance with professional standards of practice for two of 41 residents reviewed, Residents #12 and #208. Specifically, (a) Resident #208, the bowel protocol was not initiated per physician orders after more than three days of the resident not having a documented bowel movement and (b) Resident #12 had a super-pubic catheter placed with dressing changes ordered daily, the dressing change was not changed over a period of 10 days, and a culture was obtained as ordered labeled with the wrong location causing a delay in care and the resident to be prescribed broad spectrum antibiotics empirically. Findings include: Facility policy titled Resident/Patient Bowel Program for Constipation (undated) documented the purpose was to provide residents at the facility interventions for constipation prevention and to monitor resident's bowel habits. Nurses would monitor resident bowel management daily in the electronic health record. If a resident did not have a bowel movement within three days, and had not been care planned otherwise, the charge nurse on the 3:00 PM to 11:00 PM shift initiated a resident bowel program worksheet. On day three, magnesium hydroxide (laxative to relieve constipation) is administered on the 3:00 PM to 11:00 PM shift and was documented on the Medication Administration Record and the Bowel Program Worksheet. Further steps to follow were outlined if the resident continued to not have a bowel movement. Resident #208 Resident #208 was admitted to the facility with the diagnoses of fracture of upper and lower end of left fibula (the long, slender bone located on the outer side of the lower leg), rhabdomyolysis (a serious and potentially life-threatening medical condition involving the rapid breakdown of damaged skeletal muscle) and hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 06/05/2026 documented the resident could make themselves understood and understand others and had intact cognition. Record Review: The Comprehensive Care Plan with focus constipation initiated 06/01/2026 documented Resident is at risk for constipation related to decreased mobility. Goal was documented as Resident will have a normal bowel movement at least evert one to three days through the review date. Interventions initiated 06/01/2026 included: Administer bowel medication per physician orders, follow facility protocol for bowel management, and record bowel movement pattern each day. Describe amount and consistency. Review of Certified Nurse Aide documentation for Bowel Task Sheet documented the following: On 06/03/2026 at 9:30 PM, Resident #208 had a medium sized bowel movement. On 06/04/2026 at 5:35 AM and 7:45 PM, Resident #208 was documented to not have a bowel movement. On 06/05/2026 at 5:23 PM, Resident #208 was documented to not have a bowel movement. At 9:24 PM, not applicable was documented regarding size of bowel movement. On 06/06/2026 at 4:33 AM, Resident #208 was documented to not have a bowel movement. At 10:46 PM, not applicable was documented regarding size of bowel movement. On 06/07/2026 at 6:19 AM and 2:06 PM, Resident #208 was documented to not have a bowel movement. At 9:30 PM, not applicable was documented regarding size of bowel movement. On 06/08/2025 at 5:01 AM, Resident #208 was documented to not have a bowel movement. At 2:33 PM, it was documented that the resident had a large bowel movement. Review of the Medication Administration Record documented a physician order for magnesium hydroxide give 30 cubic centimeters (cc) by mouth every 24 hours as needed for constipation as per bowel program, Day #3 of no bowel movement. Give on 3:00PM- 11:00PM shift. This medication was not marked as administered to the resident on 06/03/2026 through 06/08/2026. Interviews: During an interview on 06/08/2026 at 12:58 PM, Resident #208 stated they were having issues with constipation, and it has been a couple of days since they had a bowel movement, but they were not sure exactly how long it has been. They stated they were only provided with prune juice to help with constipation, and they were not given any other medications or treatments for constipation. During an interview on 06/11/2026 at 11:18 AM, Certified Nurse Aide #8 stated aides were expected to document in the electronic health record on bowel movements for the residents on their assignment each shift, even if the resident did not have a bowel movement. They stated they documented what size bowel movement the resident had. They stated the nurses could see in the electronic health record if a resident has not had a bowel movement in three days, and then the nursed initiated the bowel protocol. During interviews on 6/11/2026 at 12:30 PM and 06/12/2026 at 10:07 AM, Licensed Practical Nurse #9 stated certified nurse aides documented daily if residents had a bowel movement. If after three days there were no bowel movements documented for a resident, they started the bowel protocol. They stated it was not documented that Resident #208 had a bowel movement on 06/04/2026 through 06/07/2026. After reviewing their electronic health record, there was no documentation the bowel protocol was initiated for this resident. They would have expected the bowel protocol to have been initiated for Resident #208. During an interview on 06/12/2026 at 2:34 PM, Director of Nursing #1 stated the bowel protocol was initiated after a resident did not have a bowel movement for three days. After the third day of the resident not having a bowl movement, magnesium hydroxide was administered to the resident on the evening shift. Residents had standing orders for the bowel protocol. Resident #12 Resident #12 was admitted to the facility with diagnoses of bipolar disorder, in partial remission, most recent episode hypomanic (chronic mental health condition characterized by extreme mood fluctuations), anxiety disorder (common mental health condition that involves excessive fear, worry, or nervousness that interferes with daily life), and infection and inflammatory reaction due to indwelling urethral catheter (a tube inserted through the urethra into the bladder to drain urine, prolonged use can lead to infection and inflammatory reactions). The Minimum Data Set, dated [DATE], documented that the resident could usually be understood, could understand others, and was mildly cognitively impaired. The facility policy titled Notification of Change in Resident/Patient Condition reviewed 09/2025, documented the Registered Nurse and/or Nursing supervisor where responsible to timely notify the practitioner regarding an acute change of condition, including the change in health condition of a resident. Record Review: Progress Note title Visit Encounter by Nurse Practitioner #1 dated 10/08/2025, documented a visit for drainage at super-pubic catheter site. The resident's family member was consulted via telephone and reported to Nurse Practitioner #1 on 10/06/2025 they had reported to the nurse there was drainage with blood tinge present on the dressing. They then removed the dressing and noted foul smelling blood-tinged purulent drainage at site. They then ordered a culture to be obtained the site and dressing to be closely monitored with dressing changes as ordered. Review of Facility Incident report documented, Resident #12 had surgical placement of a super-pubic catheter on 09/22/1016, the dressing was changed on 09/29/2025 as ordered and then not changed again until 10/08/2025. Registered Nurse #2 was made aware on 10/06/2025 by a family member of the resident that they were concerned about the surgical site and dressing, the dressing was not changed, and a provider was not notified. A wound culture was ordered for the super-pubic site on 10/08/2025 and was labeled incorrectly by Registered Nurse #2 as the site being right thigh, the culture came back positive for bacteria, however there were concerns about the integrity of the culture. The resident was treated empirically with an antibiotic at that time. Review of Registered Nurse #2 included in the facility investigation documented, Registered Nurse #2 placed orders on 09/26/2025 for Dry gauze over suprapubic catheter site, Change dressing and assess every evening shift for suprapubic catheter site, clean site first and on10/06/2025 for Dry gauze over suprapubic catheter site, Change dressing and assess every night shift for suprapubic catheter site, clean site first incorrectly causing the order not to be transferred onto the Treatment Administration Record. Review of the Treatment Administration Record for 10/2025, documented: There was no documented evidence or orders for super-pubic catheter site dressing changes on Treatment Administration Record 10/2026 for orders placed on 09/26/2025 or 10/06/2026. Dry gauze over suprapubic catheter site, change dressing and assess every shift for suprapubic catheter site for 7 Days, clean site first, was added on 10/08/2025. There was no documented evidence of a dressing change with assessment on 10/10/2025 for the 7 AM-3 PM sift. Interviews: During an interview on 06/10/2026 at 11:27, Registered Nurse #1 stated their recollection of the incident with Resident #12 in October 2025 was an order was placed and not followed for supra-pubic catheter dressing changes and culture specimen was sent to lab with the wrong identification of site. Registered Nurse #2 had entered the orders incorrectly, not flagging them in the treatment administration record for the nurses to follow on their shifts. This caused the start of antibiotics empirically. During an interview on 06/15/2026 at 8:50 AM, Nurse Practitioner #1 stated Resident #12 had a Super-pubic catheter placed in late September of 2025 for recurrent urinary tract infections. The sister reported to them during their visit with the resident regarding changing their status in the facility from rehabilitation to long term care placement, on 10/06/2026 that they spoke with nurse manager about the dressing not being changed and their concerns there was an issue at the site. Nurse Practitioner #1 assessed the super-pubic site and noted dressing with drainage that had not been changed, they then had reported dressing not being changed to nurse manager and Director of Nursing, and had ordered cultures. Their expectation was the nurse manager was to address any issue when brought to their attention then bring to the attention of the Nurse Practitioner in the building as soon as possible, not doing so was a delay in care. Culture expectations where the culture was obtained and labeled correctly, not doing so also caused a delay in care. The resident had a high potential for sepsis after surgery. When they were made aware that the culture was not obtained and labeled properly, they started a broad-spectrum antibiotic empirically. During an interview 06/15/2026 at 11:02 AM, Medical Director #1 stated they would expect all dressing changes to be done as ordered. They were not made aware of the situation with Resident #12 in October and would have expected to have been. Expectation would be when the family member had reported to a nurse the dressing had not been changed, the nurse would change the dressing and monitor the site, as well as notify the Nurse Practitioner in the building immediately. 10 New York Codes Rules and Regulations 415.12

Based on observation, interview, and record review, during the survey, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary assistance with eating, maintaining personal hygiene, and adequate grooming, for two (Residents #77 and #188) of five residents reviewed. Specifically, Resident #77 was observed unkept with dirty fingernails; Resident # 188 was not offered or provided the opportunity to get out of bed until the surveyor pointed it out to the assigned Certified Nurse Aide at lunchtime, despite the resident being awake and wanting to eat breakfast. The resident was observed on 6/08/2026 throughout the morning to be pleasantly confused, awake, in bed and to have a breakfast tray that remained in the room, until lunchtime when staff replaced it with a lunch tray. Staff interview confirmed that Resident # 188 did not receive the required assistance to access and consume breakfast. Resident interview confirmed he would like to have eaten breakfast. Findings include: The facility policy titled, Shower Procedure last revision date of 12/2025 documented residents will be offered a shower when indicated by the plan of care. The facility policy titled Activities of Daily Living Mobility dated 9/2024, documented that based on the comprehensive assessment of each resident, care and services will be provided to maintain their current activities of daily living status. Care and services for the following activities of daily living included hygiene (bathing, grooming, and oral care), mobility, elimination, and dining (eating). Staff must talk with each other about what their residents are doing. Resident #77 Resident #77 was admitted to the facility with diagnoses of type 2 diabetes (a chronic condition where the body either doesn't produce enough insulin or cannot properly use the insulin it produces, leading to high blood sugar levels), Alzheimer's Disease and Hypertension. The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment and is sometimes understood. The Activities of Daily Living Comprehensive Care Plan dated 3/13/2026 documented that Resident #77 had an activity of daily living self-care deficit related to Alzheimer's Disease, weakness and an inability to walk. The resident required substantial assistance for bathing, and partial assistance for personal hygiene. The Kardex dated 06/15/2026 documented Resident #77 required a Hoyer lift for transfer, partial assistance with personal hygiene, substantial assistance of one for bathing. The record did not indicate a day of the week for a shower/bath. The Certified Nurse Aide Documentation Record dated 06/01/2026 -06/10/2026 documented; personal hygiene including washing drying face/hands for Resident #77 and lacked documented evidence of any staff initials for 6/08/2026 & 06/10/2026. The record lacked documented evidence of a bath or shower provided from 06/01/2026- 06/10/2026. During an observation on 06/08/2026 at 11:34 AM Resident #77 was observed sitting in his wheelchair, the residents' nails were observed with brown material under all of them. During an observation on 06/11/2026 at 11:30 AM, Resident #77 was observed sitting in their wheelchair in their room. The resident was observed with brown material under the bilateral fingernails and was unshaven. Licensed Practical Nurse #10 was present and stated yes, there was a brown substance under the resident's nails of both hands. During an interview with Licensed Practical Nurse #10 on 06/11/2026 11:35 AM, they stated the resident was scheduled for Wednesday's day shift showers, and there was no documentation that the resident got a shower yesterday. They are unsure of who cared for Resident #77, as the unit assignment sheet was not correct. Licensed Practical Nurse #10 stated the resident did not get his scheduled shower, and the resident's hands and nails should be cleaned with am care and as needed. Resident # 188 Resident #188 was admitted to the facility with diagnoses of unspecified dementia (progressive disorder that affects memory), heart failure (chronic condition in which the heart is unable to pump blood effectively) and spinal stenosis (narrowing of the spinal canal). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment, is understood and able to understand others, required supervision or touching assistance with eating, substantial/maximal assistance with toileting hygiene, shower/bathe, dressing and transfers. The Kardex dated 06/09/2026 documented to encourage and assist Resident out of bed prior to breakfast and out of bed for all supervised intake in room. The resident required supervision for eating. The Activities of Daily Living Comprehensive Care Plan dated 12/29/2023 documented intervention included, (12/1/2025) to ensure Resident #188 is out of bed before breakfast, supervision after set up for eating with scoop plate/built up utensils. (5/29/2026) supervision after set up, prompt and encourage resident to be up in wheelchair for all meals and medication administration, have head of bed elevated to 60-90 degrees, if unable to tolerate 90 degrees maintain 45 degrees head of bed elevation during intake- maintain upright position more than 45 degrees for 30-45 min post meal, staff to verify positioning before meal tray delivery- monitor for coughing, wet voice, pocketing. The Certified Nursing Task dated 06/08/2026 was reviewed and breakfast intake had no entry. The task was verified with assigned Certified Nurse Aide # 9 that the resident did not receive breakfast, they were not offered, and the resident did not refuse. During an observation on 06/08/2026 at 10:45 AM and 12:37 PM. Resident # 188 was observed with their breakfast tray in the room, not within reach, untouched, and unopened. The surveyor asked the resident if they wanted to eat, they stated, yes. The resident was observed to be awake, the room was dark, and the resident was confused about the time of day. During an interview on 06/08/2026 12:30 PM with assigned Certified Nurse Aide #9, they stated they were assigned Resident # 188 today. Certified Nurse Aide #9 verified Resident # 188's breakfast tray was untouched and unopened with the surveyor. Certified Nurse Aide #9 stated the resident needed assistance with meals, and the resident would not be able to reach their tray on their own and Resident # 188 required set up assistance. Resident #188 was asked if they would like to get up out of bed at 12:30 PM during the tray observation and the resident reported yes. They stated they did not deliver the resident their tray and they are not familiar with Resident #188 and did not offer the resident breakfast or offer him to get up, but they would do it now. Certified Nurse Aide #9 stated they were not aware that the resident did not eat breakfast. During an interview on 06/08/2026 12:35 PM Certified Nurse Aide #11, they stated they delivered Resident # 188 their breakfast tray, and that is how we do it every day. They stated they delivered their tray and it is supposed to be left at bedside until the resident gets up. Whenever the resident gets up then they eat or drink. If the resident is not up and lunch arrives, they take the breakfast tray and replace it with the lunch tray. During an interview on 6/15/2026 at 10:15 AM with assigned Certified Nurse Aide #5 they stated Resident # 188 does not need to be supervised when eating. During an interview on 6/15/2026 with the assigned Licensed Practical Nurse #10, they stated Resident #188 should be offered breakfast every day. If the resident is sleeping, the resident should be offered breakfast by waking them up. Everyone should be offered breakfast before lunchtime. Resident #188 stated that the resident required supervision after tray setup and cannot eat in their room alone. During an interview with the Director of Nursing on 6/12/2026 at 2:45 PM, they stated staff should observe what's left on the resident's meal tray. Staff would know if a resident did not eat breakfast by looking at what is left on the tray and offering alternatives or looking for a reason if it was not eaten. Staff should circulate the hallway and stick their heads in the residents' rooms often. Resident #188 is required to be out of bed for meals. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

Based on record review and interviews conducted during a survey, the facility failed to ensure that comprehensive care plans were developed and implemented for residents according to professional standards for three (Resident #'s 12, 15, and 87) of 41 residents reviewed. Specifically, (a.) Resident #87 did not have a care plan for their respiratory diagnosis or use of oxygen; (b.) Resident #15 had a 16.25% weight loss from 10/28/2025-04/15/2026 and there was no care plan for it; (c.) Resident #12 was care planned for super-pubic urinary catheter care including daily dressing changes; it was not implemented in 10/2025 when the dressing was not changed for multiple days.The findings include:The facility policy titled Interdisciplinary Care Plan reviewed 9/2025, documented that the objective was to provide a person-centered plan of care that would establish continuity between all departments and maintain objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that were identified. The facility would (1.) develop and implement a baseline care plan; (2.) assess and evaluate the resident's conditions; (3.) perform specific assessments/evaluations per policy and procedures for admissions; (4.) utilize assessments/evaluations and other related information, imitate appropriate care plan; (5.) individualize each care plan noting resident specific needs, measurable goals, and approaches and responsible disciplines; (6.) assess resident goals; (7.) and include interventions/approaches to direct care delivery. (a.) Resident #87 Resident #87 was admitted to the facility with diagnoses of major depressive disorder recurrent (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life), chronic respiratory failure with hypoxia (when the respiratory system fails to maintain adequate gas exchange, resulting in low oxygen levels), and dependence on supplemental oxygen (medical condition in which a person requires oxygen therapy for an extended period to maintain adequate oxygen levels in the blood). The Minimum Data Set, dated [DATE], documented that the resident could be understood, could understand others, and was mildly cognitively impaired. Review of prescriber orders documented, Oxygen continuously at 2 Litters via nasal cannula every shift for hypoxia (condition where body's tissues and cells do not receive enough oxygen to function properly). Review of the comprehensive care plan revealed no documented evidence of any respiratory care area or use of oxygen therapy. Resident #15 Resident #15 was admitted to the facility with the diagnoses of pulmonary hypertension (high blood pressure in the arteries of the lungs), protein-calorie malnutrition (potentially life-threatening condition caused by an inadequate intake of protein, calories, or both), and chronic atrial fibrillation (continuous, irregular and often rapid heartbeat). The Minimum Data Set (an assessment tool) dated 4/15/2026, documented the resident could be understood, could understand others, and was moderately cognitively impaired. The Weight Summary dated 10/25/2025-05/05/2026 documented a 16.25% weight loss from 10/28/2025-04/15/2026. The Nutrition/Dietary Note dated 4/22/2026 documented significant weight loss for 6 months. A review of the Comprehensive Care Plan documented no care plan for actual weight loss or alteration in nutritional status. Interviews: During an interview on 06/12/2026 at 9:20 AM, Licensed Practical Nurse #5 stated care plans should be updated in real time with the onset of new issues. They would expect if residents were started on oxygen there would be a respiratory care plan. They would notify a Registered Nurse of any new diagnosis onsets for the care plan to be initiated During an interview 06/15/2026 at 11:45 AM, Registered Nurse #1 stated they would expect there to be a care plan with interventions in place for significant weight loss. They stated they did attend care conferences and participated in reviewing and updating care plans. They would assess if care plan interventions were being followed by reviewing documentation. They gave an example of a signature on the certified nurse aide accountability form, medication administration record, or treatment administration record would be present for the specific intervention. They further stated that if there was no signature, that would indicate the care plan was not followed. During an interview on 06/11/2026 at 12:00 PM, Director of Nursing #1 stated any resident using oxygen, should have a respiratory care plan that includes the use of oxygen. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on interviews and record review conducted during a survey, the facility failed to promptly notify the resident and the resident representative when there was a change in room for one (Resident #138) of two residents reviewed. Specifically, Resident #138 had a room change and the residents' representative was not given prior notice. The facility policy titled Resident Rights effective 10/2017, documented it was the facility's policy to protect the rights of all residents which included, but was not limited to the right to a dignified existence and self-determination. All residents must be supported and promoted, their right to self-determination in order to assist them in achieving their highest, practicable well-being. The resident representative had the right to exercise the resident rights to the extent those rights are delegated to the representative. The facility would treat all decisions made by the designated representative as the decisions of the resident. In regard to medical care, the resident had the right to participate in the decisions that affected their care. Resident #138 Resident #138 was admitted to the facility with diagnoses of vascular dementia (a decline in thinking and memory skills caused by restricted or blocked blood flow to the brain), encephalopathy ( a broad term for brain dysfunction, disease, or damage, characterized primarily by an altered mental state, confusion, personality changes, and potential cognitive decline), and adjustment disorder (a short-term mental health condition that occurs when an individual develops emotional or behavior symptoms in response to a specific, identifiable life stressor). The Minimum Data Set (an assessment tool) dated 5/01/2026, documented the resident was usually understood by others, usually able to understand others, and had severe cognitive impairments. During an interview on 6/08/2026 at 1:12 PM, Family Member #1 stated Resident #45 had a room change on 5/28/2026 that they were not made aware of. They stated their children went to visit Resident #45 and discovered that they were on a different unit. They stated there was very poor communication. A social work progress note dated 4/29/2026, documented Family Member #1 was under the impression that Resident #138 would be moved to another room on the S2 unit on that date. Family Member was okay with the move, should the staff decide it was best for the resident. They understood the resident's dementia and sundowning, as they were cared for Resident #138 at home prior. Social Worker #2 advised Family Member #1 that some of Resident #138's behaviors may be due to their admission to the facility. It further documented that per the unit manager, they would see whether Resident #138 adjusted before deciding to move the resident. A late entry health status note dated 5/28/2026, written by Licensed Practical Nurse #1, documented transferred to S2. Resident #138 had a room change to the S2 unit on 5/28/2026. There was no documented evidence that Family Member #1 was provided information regarding the room change, including the resident's new room number, prior to the transfer. Additionally, there was no documented evidence that Family Member #1 was informed that the room change would occur on 5/28/2026. During an interview on 6/10/2026 at 10:06 AM, Social Worker #1 stated that the facility held room change meetings every Tuesday and Thursday to discuss potential resident room transfers. They stated that families were contacted to ensure they were aware of and agreeable to any proposed room change. Social Worker #1 stated that when a room change occurred, the resident's care plan was updated and a progress note was written; however, a room change form was not utilized. They further stated that families were notified of the unit and room number to which the resident would be relocated. Regarding Resident #138, Social Worker #1 stated that the resident had cognitive impairments and that the family was agreeable with a room change to the memory care unit if the facility determined It was appropriate. However, the room change occurred without prior notification to the family. Social Worker #1 stated that Resident #138 was transferred to the unit they cover, and they were unaware of the transfer until after the resident had arrived. They stated that Family Member #1 expressed dissatisfaction with the communication process. Social Worker #1 further stated that although Family Member #1 was agreeable with the transfer to memory care, they should have been notified before the move occurred and provided with the resident's new unit and room number. Social Worker #1 stated Resident #138 has had a hard time adjusting. During an interview on 06/10/2026 at 10:45 AM, Administrator #1 stated they were not directly involved in room changes. They explained that room change meetings were held every Tuesday and Thursday and included Social Services, Ward Clerks who coordinated room changes, housekeeping staff responsible for completing the moves, and, at times, Medical Providers. Administrator #1 stated Social Services communicated with residents' families regarding room changes and obtained consent. They stated that no resident should be moved until Social Services has distributed an email confirming the room change and any necessary consent. Administrator #1 further stated they would expect the room change to be documented in the resident's progress notes. They would also expect the designated responsible party to be notified prior to the room change. 10 New York Code of Rules and Regulations 483.10(g)(14)(iii)(A)

Based on observation, record review, and interviews during the recertification survey and abbreviated surveys (NY00281127 and NY00322303) dated 10/16/2023 through 10/24/2023, the facility did not provide effective housekeeping services on five (5) of 5 resident units, the resident common areas, and nurse stations. Specifically, floors were soiled, 3 floor tiles had brown stains; a corridor wall fan was soiled; ceiling tiles were stained or soiled; walls were soiled with splatter marks, drip marks, and dirt; wall surfaces were chipped; a 5-inch diameter section of wall surface was ripped; drill holes were found in the corridor walls; the paint was chipped on the heater register; handrail surfaces were worn; and coving base was missing. This is evidenced as follows: During observations on 10/18/2023 from 11:15 AM through 12:39 PM: 1.) The floor was soiled in the H-1 Unit nurse station, H-2 Unit nurse station, and N-2 nurse station. 2.) Floors were soiled by the door frames in the room #s H-176 bathroom, H-1 quiet room, and H-258 bathroom. 3.) Floors were soiled in corners and long wall in resident room #s N-2244, N-3302, N-3324, and N-3326. 4.) The corridor wall fan on the S-2 unit was soiled with black particles. 5.) Two ceiling tiles were stained or soiled in room #H-164, one was stained in room #H-258 bathroom, one in room # H-231, 4 were soiled in the N-3 Unit west corridor by the ceiling vent, 3 were stained in the N-3 Unit north corridor; two ceiling tiles were soiled by the ceiling vent in room #H-231. 6.) Walls were soiled with splatter marks, drip marks, and dirt in the corridor outside the N-2 Unit dining area. 7.) Wall surfaces were chipped in room #s N-3302 by the bed and N-3324 outside the bathroom and the H-2 Unit dining area. 8.) A 5-inch diameter section of wall surface was ripped in room #H-258. 9.) 8 drill holes were found in the corridor outside room #S-212. 10.) Paint was chipped on the heater register in room #H-225. 11.) Handrail surfaces were worn on the H-2 Unit and S-2 Unit by dining areas. 12.) Coving base was missing in the H-1 unit common area and in the corridor by room #N-2233. 13.) Eight floor tiles were worn in the corridor by the H-1 Unit dining area. The document undated titled Housekeeping Porter 1st Shift documented that floors and walls in resident rooms and corridors were to be cleaned but was silent on cleaning nurse station floors and corridor wall fans and reporting maintenance issues such as worn handrails, stained ceiling tiles, and worn floor tiles. The undated Housekeeping Cleaning Schedule documented that floors and walls in resident rooms and corridors are to be cleaned but was silent on cleaning nurse station floors and corridor wall fans and reporting maintenance issues such as worn handrails, stained ceiling tiles, and worn floor tiles. During an interview on 10/19/2023 at 1:45 PM, the Director of Facilities stated that being new to the job (hired two months ago), some environmental issues were inherited. The Director of Facilities stated that the facility was aware of many of the cleaning and maintenance issues, staff would be assigned to start the cleaning, and a new cleaning schedule would be developed. During an interview on 10/19/2023 at 1:49 PM, the Administrator stated that the areas identified would be put on the house-wide routine cleaning schedule, and a broad audit would be conducted to identify any other areas that need repair or cleaning. The Administrator stated that the Director of Facilities would be directed to enter the maintenance items into the facility computerized maintenance schedule. 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Based on observation, record review, and interviews during the recertification survey dated 10/16/2023 through 10/24/2023, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for five (5) of 5 resident unit kitchenettes and the main kitchen. Specifically, a can of cherry pie filling with a dent with metal touching metal was found ready for use in the dry storage area speed rack. When checked, the concentration of quaternary ammonium compound (QAC) in use for sanitizing food contact surfaces was found to be 100 parts per million (ppm) when measured at 80 degrees Fahrenheit (F). The following areas in the main kitchen were soiled with food particles, food splatters, and/or grime: can opener and holder, walk-in refrigerator door around the handle, wall fan, tray rack [NAME], ceiling by the labeling machine had food splatters. In the N-2 Unit nourishment station, the refrigerator door gasket, bottom of refrigerator, cabinet below the sink, and floor next to cabinets were soiled with food particles, food spills, and/or dirt. In the N-3 Unit nourishment station, the microwave oven, cabinet below sink, and floor next to walls were soiled with food particles and/or dirt. In the S-2 Unit nourishment station, the microwave oven and floor next to walls were soiled with food particles or dirt, and the particle board base bottom of the cabinet below the sink was cracked, broken, and caved in from water damage. In the H-1 Unit and H-2 Unit there was soiling within the kitchen and ABC nourishment stations. This is evidenced as follows: Finding #1: During observations on 10/16/2023 at 10:10 AM through 11:44 AM, a can of cherry pie filling with a dent with metal touching metal was found ready for use in the dry storage area speed rack. During an observation on 10/16/2023 at 10:33 AM, the General Manager, Food Service, was observed discarding a dented can of cherry pie filling. The document titled Canned Food Safety dated 2014, documented that cans with a severe dent in the seam (photograph in the doucment illustrated a dented can with metal touching metal) are to be thrown away and not used. During an interview on 10/16/2023 at 10:33 AM, the General Manager, Food Service, stated that the dented can of cherry pie filling should not have been placed on the rack by the receiver (person that stocks the speed rack), the receiver had received training but will be re-educated on which dented cans were and were not acceptable for use. Finding #2: The label on the undated bottle of Diversay J-512 Sanitizer documented that the quaternary ammonium compound (QAC) concentration for use when sanitizing food contact surfaces was to be between 200 ppm and 400 ppm of QAC. During observations on 10/16/2023 at 10:10 AM through 11:44 AM, when checked, the concentration of quaternary ammonium compound (QAC) in use for sanitizing food contact surfaces was found to be 100 parts per million (ppm) when measured at 80 degrees Fahrenheit (F). The undated document titled Manual Dishwashing, the instruction training for employees manually washing food contact equipment with an accompanying log sheet, documented that the concentration of QAC is to be between 200 ppm and 400 ppm. The document did not include how often the sanitizing solution should be changed. During an interview on 10/16/2023 at 10:49 AM and again at 10:53 AM, the General Manager, Food Service, stated that the sanitizing solution in the 3-compartment sink was ready for use. The surveyor checked the concentration of QAC, and the General Manager, Food Service, stated that the solution was too dilute. Finding #3: During observations on 10/16/2023 at 10:10 AM through 11:44 AM, the following areas in the main kitchen were soiled with food particles, food splatters, and/or grime: the can opener and holder, walk-in refrigerator door around the handle, wall fan, tray rack [NAME], ceiling by the labeling machine had food splatters. In the N-2 Unit nourishment station, the refrigerator door gasket, bottom of the refrigerator, the cabinet below the sink, and the floor next to cabinets were soiled with food particles, food spills, and/or dirt. In the N-3 Unit nourishment station, the microwave oven, cabinet below sink, and floor next to walls were soiled with food particles and/or dirt. In the S-2 Unit nourishment station, the microwave oven and floor next to walls were soiled with food particles or dirt, and the particle board base bottom of the cabinet below the sink was cracked, broken, and caved in from water damage. In the H-1 Unit and H-2 Unit nourishment station, the bottoms of refrigerators were soiled with food particles. The undated document titled Associate Daily and Weekly Cleaning Schedule documented that can openers, utility carts, refrigerators, and nourishment station refrigerators were to be cleaned daily and (walk-in) refrigerator doors were to be cleaned weekly. It did not include cleaning nourishment station microwave ovens, cabinets, and floors. During an interview on 10/16/2023 at 1:34 PM, the General Manager, Food Service, stated that a Food Service Worker was assigned to clean the nourishment station refrigerators. Interviews: During an interview on 10/19/2023 at 2:42 PM, the General Manager, Food Service, stated that the pot washer employee that prepared the QAC needs further education on how to maintain the concentration of QAC including refilling the sinks more often. The General Manager, Food Service, stated that most of the soiled items found during survey were missed as staff required more education, but these items have been cleaned. The General Manager, Food Service, stated that weekly audits would be conducted to monitor the QAC concentration and the kitchen cleanliness. During an interview on 10/19/2023 at 3:00 PM, the Administrator stated that the dietary department will be consulted to ensure the training and auditing as stated by the General Manager, Food Service, (cleaning, use of the 3-bay sink sanitizer, and disposition of dented cans) would be implemented. 10 NYCRR 415.14(h)

Based on observations and interviews during the recertification survey from 10/16/2023 through 10/24/2023, the facility did not maintain drugs and biologicals labeled in accordance with currently accepted professional standards on 3 of 6 medication carts. Specifically, for the Homeward Bound (HB) Unit, the facility did not ensure medications on HB Medication Cart #2 (an opened, unlabeled insulin pen and an expired bottle of bisacodyl) were stored in accordance with facility policy and accepted professional principles, for the H2 unit, the facility did not ensure medications on H2 Medication Carts #1 (an opened, unlabeled insulin pen) and #2 (an opened, unlabeled insulin pen and an unrefrigerated bottle of cephalexin) were stored in accordance with facility policy and accepted professional standards. This is evidenced by: The policy and procedure (P&P) titled, Medication, General Principles of Administration and Storage, reviewed 10/2023, documented multi-dose vials which have been opened or accessed (e.g., needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. HB Unit During an observation on 10/20/2023 at 02:34 PM, a bottle of bisacodyl tablets, dated 09/2023, and an open insulin pen that did not include documentation of the date it was opened were present in the HB Unit Medication Cart #2. During an interview on 10/20/2023 at 02:34 PM, Licensed Practical Nurse (LPN) #6 stated they were assigned to the HB Unit Medication Cart #2 for the shift. The bisacodyl tablets should not be in the cart since they were expired. They reviewed their carts sometimes for expired medications, but not always; they were an agency nurse. The insulin pen would have to be discarded since there was no way to determine when it had been opened; the date it was opened should have been documented on the pen when it was opened. During an interview on 10/23/2023 at 09:31 AM, LPN #5 stated medications like insulin needed to be labeled and dated, insulin pens were good for 30 days from the date they were opened. Normally, there were stickers available for labeling the insulin pens. Stock inventory items in the medication carts, like bisacodyl, should be checked for expiration any time they were used, and discarded if they were expired. During an interview on 10/23/2023 at 11:16 AM, Registered Nurse (RN) #2 stated medications like bisacodyl and insulin should be labeled and dated when opened. Once opened, insulin pens were kept on the medication carts, and discarded after 28 days. Stock items, like bisacodyl, should be checked by the nurse any time they are dispensed for administration. During an interview on 10/23/2023 at 09:48 AM, the Director of Nursing (DON) stated the nurse managers regularly audit the medication carts, but the medication nurses were responsible for ensuring there were no expired medications on the carts. An expiration date should be documented on insulin pens once they were opened, per facility policy this was 28 days unless otherwise specified by the manufacturer. H2 Unit During an observation of Medication Cart #2 on 10/2023 at 11:03 AM, an glargine insulin pen was unrefrigerated and an open Humalog pen was not labeled with an expiration date. During an observation of Medication Cart #1 on 10/20/2023 at 12:08 PM, a Humalog insulin pen was opened and not labeled with an expiration after opening date and a bottle of cephalexin oral suspension was not refrigerated. During an interview on 10/20/2023 at 11:03 AM, Licensed Practical Nurse (LPN) #7 stated they thought the insulin would expire 30 days after it was opened. LPN #7 stated they didn't know of any policy addressing expiration of insulin. During an interview on 10/20/2023 at 12:08 PM, LPN #8 stated they thought the insulin would expire 30 days after it was opened. LPN #8 stated the resident who was prescribed the cephalexin expired the day before. 10 NYCRR 415.18(d)

Based on observation, record review, and staff interview during a recertification survey the facility did not ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)) and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infections and prevent new ulcers from developing or worsening for one (1) (Resident #231) of four (4) residents reviewed for pressure ulcers. Specifically, for Resident #231, the facility did not ensure; the resident's risk of developing a pressure sore from the resident's newly prescribed orthopedic boot was identified; that the resident's complaint of right ankle burning under an orthopedic boot was monitored from 8/17/17 through 8/19/17; that interventions were initiated for the resident's complaint; and did not ensure the provider was contacted for direction regarding the resident's complaint, resulting in the discovery of the development of a Stage I pressure sore on the resident's right lateral ankle on 8/19/17. Additionally, the facility did not ensure the provider was notified of the discovery of a stage I pressure sore, and did not monitor or evaluate the pressure sore from 8/19/17 through 8/21/17, resulting in the worsening of the pressure sore from a stage I to a stage 3 pressure sore. This is evidenced by: Resident #231: The resident was admitted on [DATE], for rehabilitation and nursing care due to a right bimalleolar (break in the lower ends of the fibula and tibia) fracture and ruptured left patellar (knee) tendon. He was status [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was able to understand others and was understood. The resident's Brief Interview for Mental Status (BIMS) score was 15/15; no cognitive deficits for decisions of daily living. A facility policy titled document titled Pressure Ulcer (PU) and Ulcer Assessment/Documentation dated 4/17/17, signed by the Medical Director and Director of Nursing (DON) documented the following: 1. Nursing - Notify nurse of any redness (It's important to report areas at once). 2. Registered Nurse (RN) - Wound Care Nurse (WCN)/designee to assess area according to Centers for Medicare and Medicaid (CMS) Guidelines (Determine if involved area is a true PU, related to pressure or secondary to other causes). 3. RN/Licensed Practical Nurse (LPN) - Initiate a Skin/Wound Referral in the medical record (Wound Nurse and Dietary will review). 4. RN - Initiate Interdisciplinary Care Plan (ICP). 5. RN/LPN - Consult with physician as needed (RN may initiate treatments (tx) per nursing judgement from standing orders, LPN may apply). 6. RN - Complete Braden Scale (Braden Scale to be completed when new PU found). 7. Dietary review RN Admission Assessment and Skin/Wound and referral for Alteration in skin integrity. 8. Staff - Obtain appropriate nursing equipment such as heel boots, air mattress, foam cushion, etc to relieve pressure. (ALL staff able to obtain nursing equipment/devices at any time). 9. RN - Initiate Pain Evaluation/Assessment form (Refer to policy and procedure). 10. RN/WC - continue to monitor specific area (s) weekly and as needed. Document. 11. RN/LPN - When area resolved, continue to monitor specific area(s) weekly x 4. Document in the medical record. Review of a consultation report dated 8/17/17, from the resident's orthopedic doctors visit, documented the resident had a right lateral malleolus fracture and a left patellar (knee) tendon rupture. The follow up orders documented the resident should not weight bear for 2 weeks, then may weight bear as tolerated (WBAT) with control ankle motion boot (CAM boot) (below the knee orthopedic device used to treat and stabilize severe sprains, fractures, and tendon tears in the ankle) and can start Physical Therapy (PT). Review of nursing progress notes from 8/17/17 through 8/22/17: 8/17/17 (Thursday) - Documented the resident had a follow up with the orthopedic physician and returned to the unit with new orders and a CAM boot to right ankle. 8/17/17 at 7:23 pm - A health Status Note written by an RN documented the resident was concerned about a burning pain in his right ankle under the CAM boot. It documented that the right ankle surgical incision site had no drainage, there was no redness and only minimal swelling noted. There were no signs and symptoms of infection. 8/19/17 (Saturday) - A Skin/Wound Referral note written by an RN, documented the RN was called to assess the area on the resident's ankle. It documented areas rubbed, pink and red, but no bleeding. It documented the RN advised the LPN to cleanse the area with normal saline and cover with gauze every shift and as needed. It also documented to make sure that the wound nurse sees the area on Monday. There were no signs or symptoms of infection or other problem at this time. It documented that staff had been instructed to alert the supervisor if there were any changes to the area or its appearance. 8/20/17 (Sunday) at 3:29 pm - Documented positive CMST's (color, motion, sensation, temperature) to BLE (bilateral extremities). It documented the resident tolerated treatment to right ankle, no signs or symptoms of infection. 8/21/17 at 8:00 am - A note written by an RN documented the area on the right lateral malleolus (ankle) was assessed. It documented the resident stated he received a CAM boot on 8/17/17, after having had a cast for 5 weeks and that he felt some discomfort in this area. It documented that the CAM boot was lined with a soft foam material which the resident felt had rubbed along the area and that when he removed the boot he noticed the area. It documented that the area presented as a Stage III (pressure sore) due to granulating tissue measuring 2.2 x 0.4 x 0.1 with approximately 5% adhered yellow slough (dead tissue) noted. It documented there was a small amount of dry sero-sanguineous (composed of serum and blood) drainage on the dressing. Also, it documented a recommendation for a referral to Wound Care for evaluation and treatment. In the interim, recommend using Calcium Alginate AG and cover with [MEDICATION NAME] gentle. The secondary dressing will provide cushioning to this area. The right lateral malleolus will be observed daily by LPN's via eTAR and LPN's will refer to NP/MD as indicated. 8/21/17 at 3:13 pm - A Nutrition/Dietary note documented notification from the wound care RN that the resident had a stage III pressure injury to the right malleolus. It documented that the resident stated the CAM boot had been rubbing the area. Recommend Juven (nutritional drink) for wound healing. Review of the eTAR (electronic treatment record) dated August 2017, documented that the resident's right ankle open area was cleansed with normal saline, and covered with gauze a total of eight (8) times every shift from 8/19/17 through 8/21/17. Review of a physician order [REDACTED]. Review of the Wound Care Company's consultation dated 8/22/17 at 10:19 am, documented the resident presented with a wound over the right lateral malleolar area, not present on admission. It documented that staff reported the resident developed this area after having a splint in place. It documented staff reported the resident had developed this area after having had a splint in place. It further documented the Wound Care Nurse Practitioner's (WCNP's) assessment of the pressure sore as follows: Wound #1: full thickness ulceration (open sore or wound that develops on the skin, break in skin integrity) of the right lateral malleolus measures L: 3.6 x W: 0.3 x D: 0.0 centimeters (cm.) Noted serosanguinous (fluid leaving a wound that is yellow with blood) drainage from wound. Wound #2: full thickness ulceration of the right lateral malleolus - proximal (center) site measures L: 0.2 x W: 0.2 x D 0.0 cm. Serosanguinous drainage from wound was noted. The WCNP's assessment also documented the resident had a Stage III (Full thickness skin loss involving damage to subcutaneous (lower layer of tissue below the skin, made up of fat and connective tissues that house blood vessels and nerves). The WCNP documented that wounds #1 and #2 were stage III pressure ulcerations of the right lateral malleolus and that the wound was from the immobilizer. It documented that poor mobility was also a contributing factor. It also documented a treatment for [REDACTED]. Nursing progress note dated 8/22/17 at 11:32 am, documented that the pressure ulcer on the resident's right ankle remains a Stage III. It documented the wound care company recommended medi-honey, and that the resident's physician was called and had approved the wound centers medi-honey treatment orders. Physician order [REDACTED]. During an interview on 8/21/17 at 9:00 am, with the the Registered Nurse (RN), the RN stated the resident had a stage 1 pressure ulcer on his right ankle and was to be seen by the Wound Care Registered Nurse (WCRN) later in the day. She stated the wound developed at the facility, after the resident had a cast removed and a CAM boot applied on 8/17/17. She stated an order for [REDACTED]. During an interview on 8/21/17 at 11:15 am, with the Registered Nurse Assistant Unit Manager (RNAUM), the RNAUM stated she had not seen the resident's wound. She was not on duty over the weekend. She stated the resident would be seen today by WCRN. She stated the last report she was given before the weekend by the evening RN was that the PU was a stage #1. During an interview on 8/23/17 at 11:30 am, the LPN charge nurse stated a cushion dressing was being used for the residents' right ankle, because the PU had progressed to a stage 3 and that additional protection was needed. She stated that LPN's were changing the dressing once a day. During an interview on 8/23/17 at 2:15 pm, the resident stated he had called the orthopedic doctor to inquire about the care he was receiving when follow up was not done. He had not called the physician after the placement of the CAM boot, because he had notified the nurses multiple times about the CAM boot rubbing against the ankle. He stated the WCRN looked at the boot when she looked at the ankle on Monday and didn't think there was a problem, but added the cushioned dressing. He stated the PU had progressed from a red area when he first complained to a larger wound that was draining. He stated he would take the Cam boot off, because it was sore. He stated the RN supervisor told him to let the nurses know if he had any itching, but his sensation was limited and the wound was covered, so he couldn't really see it. During an interview on 8/23/17 at 2:50 pm, the Wound Care Registered Nurse stated the resident had been seen by the Wound Center Consult NP (nurse practitioner) on 8/22/17 and it had been determined the pressure ulcer to the right ankle had progressed to a stage III. She stated the pressure ulcer was facility acquired, after the resident had a cast removed on 8/17/17, which was replaced with a CAM boot. The WCRN assessed the resident on 8/21/17 and made the referral to the Wound Care Center. During an interview on 8/24/17 at 3:15 pm, the Director of Nursing (DON) stated when the resident complained of irritation with the newly placed CAM boot, the evening RN, who assessed the resident, should have notified the physician and that monitoring of the area should have been started. She stated that this would ensure all nurses monitored the area every shift. She stated that in order to check the ankle every shift monitoring should have been entered into the eTAR. She also stated that each nurse should have documented in the nursing progress notes, the condition of the area at the time of each dressing change and if the condition of the ankle changed an RN should have been notified to reassess the wound. She stated regular monitoring of a newly developing PU is key to early treatment and prevention of the worsening of the PU. She further stated re-education would be necessary because the nurses did not follow the policy and procedure for assessment and documentation to prevent PU from developing and worsening. During an interview on 8/24/17 at 4:00 pm, the RN office manager for the orthopedic physician stated the type of CAM boot the resident was fitted for had a bladder on the inside that could cause irritation as [MEDICAL CONDITION] resolves and the boot loosens. If the resident reported there was burning after the cast was removed and the CAM boot applied, the nurses at the facility should have addressed this or called the orthopedic physician on call for the resident to be seen. She stated there were no calls from facility staff regarding any problems from the date of the resident's last visit on 8/17/17 through 8/24/17. 10NYCRR415.12(c)(2)

Based on record review and interview the facility did not ensure it provided the necessary care and services to attain or maintain the highest practicable physical well-being for 2 ( #s- 85 and 250) of six residents reviewed for fractures during the recertification survey. Specifically, for Resident# 85, the facility did not ensure timely treatment and report an acute change in condition after the resident sustained [REDACTED]. Additionally, interventions were not developed to reflect intermediate steps for the care of the [MEDICAL CONDITION] ankle, therefore leading to a lack of monitoring of the resident's progress of the fracture that subsequently resulted in an amputation of the limb. Resident # 250 experienced pain for two days without treatment for [REDACTED]. This resulted in actual harm to both residents that was not immediate jeopardy. This is evidenced by: Resident # 85. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], assessed the resident's Brief Interview of Mental Status at 13/15 , which indicated intact cognition. The MDS further documented that the resident was able to understand and be understood. This same MDS documented that the resident had a history of [REDACTED]. The Comprehensive Care Plan (CCP) ,dated 2/25/14, documented the resident was a high risk for falls related to psychoactive drug use, gait/balance problems and was non- compliant at times with walker use and calling for assistance. There were no goals documented. The intervention column documented to review information on past falls and attempt to determine cause of falls. The next section under problems documented the, " Resident has had series of falls; 2/1/14;2/13/14 ; fell in bathroom on 2/24/14 and sustained injury to right ankle, had orthopedic appointment then to hospital for closed reduction of right ankle". The goal documented the staff would maintain current level of function without decline in Activity of Daily living(ADL) status. The Interventions documented included ;bed and chair alarm, continue interventions on the at risk plan and resident non-ambulatory, non- weight bearing; posterior U splint ( a device use to keep foot immobile) with ace wraps to right lower extremity orthopedic follow-up as scheduled and out of bed to posture guard. The Functional Status update, used by Physical Therapy, dated 2/21/14, documented the resident required assist of one with the wheeled walker for transfers and ambulation in room and on unit. The progress note, dated 2/24/14, documented the Registered Nurse (RN) was called to the resident's room. Upon arrival the Physical Therapist informed the RN that the resident was in the bathroom, while he stood outside the door to provide privacy. The resident was instructed to call him when she was finished using the restroom. The PT stated he checked on the resident frequently but then heard a noise at which time the resident was on the floor. The resident stated her right medial ankle was painful and pointed to the area. The ankle was assessed to have had immediate swelling, no redness or bruising at that time . The physician was notified and orders were received for x-rays right ankle to rule out fracture and apply ice or warm packs to right ankle as needed. A portable X-ray was taken at the facility on 2/24/14 at 10:25 am. The x-ray report , dated 2/24/14 documented a [MEDICAL CONDITION] fibular diaphyseal region ( the end of the shin bone closest to the foot) with separation and displacement up to 3 mm. The x-ray report was reviewed by the Primary Care Physician ( PCP) . The telephone order dated 2/24/14 at 4:30 pm documented an order for [REDACTED]. The progress note dated 2/24/14 documented the resident had complaints of discomfort and was medicated for pain. The next note dated 2/25/14 documented right ankle bruising around inner ankle with slight swelling and was medicated at 3:30 am with good effect. The progress note dated 2/25/14 at 7:49 am , documented a call was placed to the family and they were made awarethat the x-ray shows possible fracture and the resident would be going to the orthopedic physician that morning to be evaluated. The following note on 2/25/14 documented at 1:18 pm , that per orthopedist, resident has a fracture and was being sent to the emergency room from the orthopedic office to be admitted to the hospital. The noted written at 5:35 pm documented the resident returned from the emergency room (ER) at 4:45 pm . The orthopedic consult report dated 2/25/14, documented reason for referral ; possible fibular fracture. The diagnosis/recommendation/treatment documented by the orthopedist documented right ankle medial skin tenting with slough, dorsal pulses weak. X-ray of ankle shows it is grossly dislocated, attempted closed reduction in office , persistent dislocation. Plan; to emergency room as soon as possible for closed reduction . This is a limb threatening condition and resident is at risk for amputation. The ER report dated 2/25/14, documented the ankle was reduced by close reduction. and a U splint was applied. Instructions were sent back with the resident for pain medication , elevation of limb no weight bearing, keep splint dry and intact and follow up with orthopedist. The next scheduled orthopedic appointment was scheduled for 3/3/14. The progress notes did not consistently include documentation of the resident's condition of the limb, assessments of color, motion, sensitivity, temperature (CMST) and level of pain. The Treatment Administration Record ( TAR) or MAR , dated 2/1/14-2/28/14, did not have documentation to check CMST's. The Medication Administration Record (MAR), dated 2/1/14- 2/28/14, documented the resident received [MEDICATION NAME] 5 mg as follows: 2/24/14 @ 5 pm for right ankle pain of 7/10 . 2/25/14 @ 3:30 am no pain scale assessment documented and @ 9:00 pm for right ankle pain 8/10. 2/26/14 @ 4:00 pm for right ankle pain of 9/10. 2/27/14 @ 12:45 pm for right ankle pain of 10/10 and @ 8:30 pm for right ankle pain of 10/10. 2/28/14 @ 1:45 am for right ankle pain of 10/10, @ 1:18 pm no pain scale assessment documented and at 5:pm for right ankle pain in right ankle and back, there was no pain scale assessment documented on the MAR. There was no evidence found that the physician was made aware of the increased level of pain. The progress note dated 2/26/14 written at 6:20 am, documented that the resident had a good night , slept well, resident had no complaints of pain , even when specifically asked. Ace wrap remained in place on right leg. CMST to right foot is good. Right leg /foot elevated on pillow. The progress note dated 2/27/14 written at 3:24 am, documented the resident denied pain when asked and was noted to be resting comfortably. Resident's leg elevated on pillow. Toes cool to touch, resident denied numbness or tingling and was able to feel toes being touched. The progress note dated 2/27/14 written at 3:14 pm, documented the resident was medicated with [MEDICATION NAME] 5 mg at 12:45 pm for complaints of pain in the right ankle and stated pain was a 10/10. The next progress notes dated 2/27/14 continued to document the residents complaints of pain in the right ankle consistent with the documentation on the MAR. There was no documentation of CMST assessment of the right limb. The progress note dated 2/28/14 written at 12:32 pm, documented the resident was yelling out loudly, when asked about pain the resident continued to yell and gave no specific complaint. The Resident stated she had pain with positioning in the wheel chair. The next note documented at 3:10 pm, that the resident was screaming and yelling at 12:00 pm and was given [MEDICATION NAME] ( used to reduce anxiety) with little effect at 12:15 pm. Resident was medicated with [MEDICATION NAME] 5 mg at 1:15 pm due to yelling out and stating she had pain. The TAR, date March 2014, documented for CMST's to be checked to left lower extremity (the involved extremity was the right lower extremity and not the left) every shift. The CMST's were signed as being checked starting on the night shift of 3/4/14 through the night shift of 3/7/14. The MAR dated 3/1/14- 3/30/14, documented the resident received [MEDICATION NAME] 5 mg as follows: 3/1/14 at 12 am, for right ankle pain of 7/10, at 8:30 am for right ankle pain of 6/10, at 2:00 pm for right ankle pain no pain scale assessment documented and at 6:00 pm for right ankle pain of 9/10. 3/2/14 at 4:00 am for right ankle pain of 7/10, 8:30 am for right ankle pain of 6/10 and at 2:00 pm and 8:00 pm no pain scale assessment documented either time. 3/3/14 at 7:30 am for pre- orthopedic appointment . The same MAR documented the resident was medicated with seven doses of [MEDICATION NAME] ( used to reduce anxiety ) between 3/1/14 and 3/3/14 for increased anxiety. There was no evidence found that the physician was made aware of the increased level of pain and anxiety. The resident was seen on 3/3/14 by the orthopedic surgeon for follow up of ankle fracture. The diagnosis/recommendations, and treatment documented ; right ankle was reduced on x-ray today, will set up for surgery on 3/7/14 to allow soft tissues to recover. The preoperative report dated 3/7/14, documented the resident had an ankle dislocation that was unreduced ( not in alignment) for at least 24 to 36 hours. The resident and family both understood that the soft tissue compromise medially could potentially lead to a below-the knee amputation. When the splint was taken down the resident had massive soft tissue necrosis ( dead tissue) medially. She had full thickness skin necrosis with holes that were at least 1 centimeter (cm) and 2 cm in diameter that allowed full view into the ankle joint. The surgeon then went out to talk to the family regarding the condition and the need for amputation of the limb. The family agreed and the surgery proceeded. During an interview on 4/7/14 at 3:20 pm, the PCP physician stated that the x-ray results from the films taken at the facility was questionable. He stated that there was a questionable [MEDICAL CONDITION]. He stated he saw the resident and she was comfortable and offered no complaints of pain. He further stated the resident was then seen on 2/25/14 by the orthopedic physician. During an interview on 8:15 am, the unit clerk stated that she had notified the orthopedic office on 2/24/14 to schedule an appointment for the resident. The orthopedic office nurse took the information and said she would call back. The unit clerk stated that the office nurse stated she had spoken to the physician and advised the facility to send the resident to the ER. The unit clerk stated that the PCP stated it could wait until the next day. The unit clerk called the orthopedic office back and an appointment was scheduled for the next day (2/25/14) at 8:20 am. During an interview on 4/8/14 at 11:40 am, Registered Nurse (RN) # 1 stated she observed the residents foot on 2/25/14 and the ankle was bruised and swollen. She stated the resident denied pain at that time and was then transported to the orthopedic appointment. During an interview on 4/8/14 at 8:35 am, Registered Nurse (RN) # 2 stated that the resident was transferred from the first floor unit to the second floor unit on 2/25/14. She stated that it would be expected that recommendations made by the orthopedic physician be followed, but if no recommendation came back with the resident a nurse would not call the orthopedic office and ask questions. She stated that the nursing staff monitored the foot closely, but could not provide documentation to show what was monitored and how often. The RN stated that the resident was not in pain from the ankle, but was having pain mostly in her back and was medicated with effect. During a second interview on 4/8/14 at 12:10 pm , the PCP stated that there was question on the first x-ray of a fracture and his assessment did not reveal an urgent need for the resident to be seen in the ER. He stated that the resident was seen by the orthopedic surgeon on 2/25/14 and her immediate plan was to amputate the limb. He stated he was somewhat surprised at that . He stated he did not call or contact the orthopedic physician to discuss the resident's fracture or the situation. He stated he had no need to as he read the reports as a physician and found no need to ask questions of the specialist. During an interview on 4/10/14 at 9:10 am, the Certified Nursing Assistant (CNA) stated that the resident had been transferred to the second floor and she was not that familiar with her. She stated that the resident yelled and screamed a lot but the CNA was told " that is how she is , she did the same thing when she was down stairs". The CNA stated she thought the resident was probably in pain because she knew she had broken her ankle, but the nurse said she always acted that way. During an interview on 4/9/14 at 8:36 am, the orthopedic surgeon stated that she had received a message from her office nurse on 2/24/14 in the later afternoon from the nursing facility who stated they had a resident with either [MEDICAL CONDITION] or ankle. She stated she instructed her nurse to let the facility know that if they suspected or had concerns that there was a fracture to send the resident to the ER as there would not be much she would be able to do in the office. She stated that the resident's PCP read the x-ray that was obtained at the facility and decided it was questionable and could what until the next day. The physician then stated that when she saw the resident in her office on 2/25/14 she obtained x-rays. She stated the ankle was grossly dislocated and detached from the leg bones. Due to the detachment of the bones and the fracture not being reduced for 24-36 hours it caused the skin to tent and slough from the bone which further caused pressure necrosis of the soft tissue. She stated she attempted to reduce the fracture in her office, but due to the degree of pain it would cause she had the resident immediately sent to the ER where a closed reduction under sedation took place. She stated she scheduled the resident to be seen again in her office on 3/3/14 with plans to schedule the resident for an open reduction. She stated the general practice for foot/ankle fractures is to wait a week or so for the soft tissue to recover before performing an open reduction. She stated that because of the wait and length of time before a closed reduction was done it put the resident at risk for amputation as the type of fracture that occurred was a limb threatening fracture. The physician stated that had she been made aware of the change in the resident's conditon related to the increase in pain she most likely would had seen the resident sooner than 3/3/14. Resident # 250 The facility did not address the resident's continued pain. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had long and short term memory problems and had moderately impaired decision making ability. Nurses notes documented: On 3/12/14 at 2:04 pm the resident was found lying on her right side with her legs slightly bent, head resting on her arms. The resident was witnessed by a staff member to have lost her balance and she attempted to grab onto a rail but was too far away from the wall and she fell on to her left side. The Nurse Practitioner was examining the resident. The resident grimaced, moaned, yelled out and guarded her left hip and femur. The doctor was called to the unit and examined the resident. New orders were received for x-rays. The resident also sustained 2 skin tears. Treatment was initiated. The resident continued to yell out when positioned in bed when lunch came. On 3/12/14 at 2:57 x-rays were obtained. The resident was screaming with any movement to the left hip/leg. On 3/12/14 at 6:16 pm the x-ray results were no fracture. On 3/12/14 at 9:47 pm the resident had no complaints of pain/discomfort this shift, however appeared to be in pain when being rolled in bed and refused all medications this shift. On 3/13/14 at 2:55 pm [MEDICATION NAME] was given for slight agitation at 8:30 am for slight agitation with good relief. The resident was assisted with two out of bed to a wheelchair. The resident was not comfortable as she complained of pain in the left hip area. Physical Therapy was made aware and the resident was placed in a Barco lounger for comfort. Therapy will be here tomorrow for evaluation. On 3/14/14 at 6:27 am the resident had increased discomforts with care and turning and positioning. While being changed the resident yelled while holding her left hip and pelvic area while grimacing and saying "no no not there". Will monitor. On 3/14/14 at 1:43 pm was informed by the charge nurse of increased peri area and pelvic pain. The resident was grabbing her groin and grimacing on and off. The resident had a glossy stare at times. The physician gave the order to send the resident to the emergency room for evaluation. On 3/15/14 at 3:36 am the facility was notified of the resident's admission to the hospital with a fractured left hip. The Medication Administration Record (MAR) for March was reviewed and there was no documentation that the resident was given Tylenol or any pain medication at any time. The physician orders [REDACTED]. The 1/14/14 Care Card (used by staff to provide needed care to the resident) documented the resident was non-ambulatory and transferred with a hoyer lift and assist of two staff. (Independent ambulation and transfer had been erased.) There was no indication that moving the resident caused pain for the resident of any guidelines to minimize pain to the resident. During interview on 4/9/14 at 9:19 am Certified Nurse Aide (CNA) # 1 stated she helped care for the resident and after the fall. The resident needed two assist for care. She stated the resident would not say she was in pain but you could tell she was in pain by her face, she cried and would yell. She stated the resident was in pain at certain times, when you put her up to feed her, and tried to turn her she would be hurting. She stated that they had to turn her about every 2 hours. She stated she let the nurse know the resident was in pain. During interview on 4/9/14 at 9:24 am CNA # 2 stated she was there the day the resident fell . She stated the resident was in pain when they got her off the floor. The resident stayed in bed the rest of that day and was in pain any time they tried to move her. She was not sure if she worked on the 13th but was there on the 14th. She stated the resident went to the hospital on the 14th because she was having so much pain whenever they tried to move her. She stated she let the nurse know the resident was in pain. During interview on 4/9/14 at 9:35 am the charge Licensed Practical Nurse (LPN), who worked from 3/12-3/14/14, stated that she had helped Mobile Imaging with the x-ray. She stated the resident was ok until they moved her on her side then she yelled and was in pain. She stated she thought she tried to give the resident Tylenol that day but the resident refused. She stated she should have written a progress note about that but didn't. She stated she knew the resident was in pain whenever she was moved and offered Tylenol but the resident refused (again no progress notes). She stated the resident often refuses medications. She stated she did not know if she let the Nurse Manager know that the resident continued to be in pain when ever she was moved and was refusing Tylenol. During interview on 4/9/14 at 10:40 am the Registered Nurse Manager stated the resident had x-rays on the 12th because of hip pain after the fall. She thought the resident was receiving Tylenol and was not told she refused it. She was shown the March MAR and asked if the resident received pain medication. She stated there was no pain medication on the MAR. She was asked what was done for the resident's pain. She stated the Barco chair. She stated that the 14th was the first she knew of the resident's continued pain. She assessed the resident and sent her out. She stated that if she had known sooner she would have addressed it, talked with the doctor. She stated the resident should have had a pain medication order on the 13th. During interview on 4/9/14 at 2:37 pm CNA # 3, an evening CNA, stated she was there the day the resident fell . She stated they cared for the resident with two assists after the fall. She stated the resident had some pain in the leg area, you could tell from her face and moaning when she was rolled. She stated they would check and change her every two hours. She stated she let the nurse know about the resident's pain. During interview on 4/9/14 at 4:18 pm the evening LPN stated that evening the resident would not take any medications. She stated the resident was in bed and was in pain any time they tried to move her. She stated she tried to give Tylenol form standing orders but the resident refused. She stated she told the next shift the resident refused all medications, the x-ray was negative but the resident was still in pain. ( It was not on 24 hour report sheet that the resident was in pain when moved and refused Tylenol.) She stated that she did not remember if she told the Supervisor that the resident had pain and refused Tylenol. She stated the resident was not lying in her room crying, she was only in pain when physically moved. During interview on 4/10/14 at 10:47 am the resident's physician stated he saw the resident after the fall. She stated there was no pain in the leg until touched and she had enough pain to warrant getting an x-ray. He stated he did not remember if he was told the resident was in pain before the 14th. He stated he would have expected to have been informed of the resident's continued pain sooner. He might have gone to assess the resident, ordered pain medication or sent her out sooner. He stated pain needs to be treated. 10NYCRR 415.12

Based on medical record review and staff interview the facility did not ensure that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (#s 38 ) of 9 residents reviewed during the standard recertification survey. Specifically, the facility did not monitor and track a subdermal hematoma which was discovered on the resident's right great toe, the resident developed an infected wound with localized [MEDICAL CONDITION] which required admission to the hospital and a surgical procedure. This resulted in actual harm for Resident #38 that is not immediate jeopardy. This is evidenced by the following: Resident #38 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident understands and is understood, and has moderately impaired cognitive skills for daily decision making. This same MDS assessed the resident was at risk to develop pressure ulcers, but did not have any current pressure ulcers present. The Braden Scale (assessment tool utilized to determine a resident's risk of developing a pressure ulcer) dated 9/2/11 assessed the resident was at risk to develop a pressure ulcer. The Podiatry Consultation form signed by the podiatrist on 10/6/11 documented the resident's right (Rt) toe had a subdermal (under the skin) hematoma and the nurse had viewed the site. The nurses notes dated 10/6/11 documented the resident was seen by the podiatrist, who noted a subdermal hematoma on the residents toe, and there were no new orders at this time. There was no documented evidence the hematoma was being monitored. A nurses note dated 12/2/11 at 11:15am documented the certified nurses aide (CNA) came to the desk to report the resident's Rt great toe blister was dripping. On observation, a dressing was noted on the Rt great toe and bloody drainage was dripping from it. After taking the dressing off, the nurse documented the great toe was reddened and had a grey appearing blister on it. The note also documented the resident was seen by the physician (MD) who stated the toe appeared to be infected and necrotic looking, and ordered the resident to be sent to the hospital for evaluation. This same nurses note documented she did not notice the resident to be uncomfortable, however, the resident did complain that her shoes were too tight and her daughter was going to bring in different shoes. The note also documented the resident was not aware she had a problem, and prior to exam, had been ambulating without complaints of discomfort. The nurses note dated 12/2/11 at 12:20pm documented the resident was transferred to the hospital. The Transfer Summary from the hospital, dated 12/7/11 documented the resident's chief complaint on admission was swelling and redness to the right great toe along with an open wound and purulent drainage. The admitting [DIAGNOSES REDACTED]. The transfer summary documented an x-ray was obtained, there was no suggestion of osteo[DIAGNOSES REDACTED]. The resident was started on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) and a wound care consult was obtained. After evaluation, the resident was scheduled for the operating room for excision and drainage. The resident underwent [REDACTED]. The antibiotics were continued and the post operative period was without complication. The nurses note dated 12/7/11 at 4:40pm documented the resident was readmitted to the facility. The nurses note dated 12/7/11 at 6:45pm documented the MD was in and the resident's Rt toe was to be cleaned with normal saline (NS), a xeroform gauze was to be applied and the toe was then to be covered with a gauze daily until healed. The nurses notes dated 12/23/11 at 2:40pm documented the resident returned from the MD with new orders. The note documented the wound was healed, area may be bathed and a dry protective dressing was to be applied daily for one week. The Treatment Administration Record documented daily dressing changes from the date of readmission 12/7/11 until 12/31/11. The Interdisciplinary Care Plan entitled "Actual/Potential Skin Integrity" dated 8/10/10 contained no documentation regarding the toe until after the readmission date of [DATE]. The Monthly Skin Observation Form initiated 10/9/10 and most recently updated 12/18/11 documented on 12/18/11 the resident's skin was intact, but a blackish/blue area was noted on the Rt abdomen. There was no documentation on this form regarding the resident's wound to the Rt great toe. During interview on 4/9/12 at 9:10am with the Charge Nurse and the Assistant Head Nurse (AHN), the AHN stated she would expect weekly monitoring of a hematoma. The AHN stated that if a resident is getting any type of treatment for [REDACTED]. The AHN also stated she was unaware of the hematoma noted on the resident's Rt great toe on 10/6/11. The AHN stated because there was no treatment ordered for the resident, we didn't realize the hematoma was there and needed monitoring. The AHN stated we dropped the ball on this one. When shown the Monthly Skin Observation Form, and the documentation dated 12/18/11, the AHN acknowledged the documentation was inaccurate, as there was no documentation regarding the resident's wound. When asked if the hematoma on the Rt great toe was being monitored weekly, do you feel the infection in the Rt great toe could have been prevented, the AHN stated yes I do, we dropped the ball. During interview on 4/10/12 at 8:30am, the resident's physician (MD) stated he expected nurses to monitor and document hematomas. The MD also stated he was unable to determine, based on the nurses note dated 12/2/11 when and why the dressing was applied to the resident's toe. The MD stated that after a resident is seen by the podiatrist, the MD will review the information on the consult report and initial. The MD stated he did initial the podiatry report dated 10/6/11, however he does not recall seeing the notation regarding the hematoma. During interview on 4/10/12 at 9:15am a certified nurses aid (CNA) who works on the unit, stated she reports any abnormal areas on a resident's skin to the nurse. If the resident has a dressing, the CNA will only report that to the nurse if the dressing is wet or dirty. The CNA also stated the nurses are responsible for changing a resident's dressing. 10NYCRR 415.12